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November 20, 2014 Thursday  
Late Edition - Final

More Clarity on Health Care

BYLINE: By ROBB MANDELBAUM

SECTION: Section B; Column 0; Business/Financial Desk; YOU'RE THE BOSS; Pg. 9

LENGTH: 970 words

Since the implementation of the Affordable Care Act, many small businesses have been intrigued by the possibility that they might be able to stop dealing with health insurance entirely and instead offer their employees a stipend to go buy insurance on the individual exchanges. But in a clarification issued in early November, the federal government appears to have taken a stand against that strategy.

There had been little doubt among most lawyers who follow the tax implications of the Affordable Care Act that a company would not be able to subsidize its employees' individual health insurance with pretax dollars (the way that premiums for group health insurance are excluded from an employee's income). But as we reported a few weeks ago, the government's guidance on using post-tax compensation was murkier. With its recent statement, the government removed some -- though not all -- of that ambiguity. 

The additional clarity came in the form of a ''frequently asked questions'' document issued by the Department of Labor. Even now, however, the issues remain complex and open to interpretation, and the tax and benefits lawyers contacted by You're the Boss offered differing perspectives on the Labor Department's answers. What better way to try to make sense of these issues than to borrow a trope from the government and present them in the form of an FAQ.

Q.

So, can a company reimburse workers for their insurance premiums with after-tax money?

A.

No. Any reimbursement scheme constitutes a group health plan, according to the Labor Department. This designation is important, because the government had already decided that a group health plan must comply with certain market reforms in the Affordable Care Act, including one that bans dollar limits for certain benefits. And a plan that reimburses members for individual policies simply cannot comply with those requirements, according to the agencies.

Businesses with plans that violate the health law's market rules can face penalties of up to $36,500 a year for each affected employee.

Up until now, there had been a debate among lawyers about whether a company could expressly reimburse individual insurance premiums with taxable income, or, if not, condition the additional compensation on buying insurance -- even if the money is not tied directly to the cost of premiums. But the latest advice from the Labor Department should end those arguments, according to four of five lawyers contacted by You're the Boss.

''What we know now is that you can't condition the receipt of after-tax money only on the purchase of insurance,'' said Christopher E. Condeluci, a Washington-based lawyer. ''Instead, you have to give the employee the choice between taking the money as cash wages or allocating that money toward the purchase of insurance.''

The one lawyer we talked to who disagreed is Seth Perretta, who represents a number of large business organizations with a stake in the various rule-makings of the Affordable Care Act. ''I can condition employment on all sorts of things,'' Mr. Perretta said. ''I can condition a subset of compensation on all sorts of things, on the employee doing lawful acts. I think it really turns on whether the regulators would agree that so long as the amount I'm paying to you is not directly related to the amount you pay for insurance, whether or not disconnecting the two would allow me to treat that as a taxable wage.'' Even Mr. Perretta said the answer was still not clear.

Q.

Suppose an owner just gives raises and doesn't specifically reimburse premiums? Can the owner tailor the amount of additional compensation for each person to the cost of health insurance without crossing the line into reimbursement?

A.

Yes, at least if the owner gives the raise unconditionally. (Mr. Perretta said it was unclear whether correlating a conditional raise would be permissible because ''we are in uncharted territory.'') For example, the raises could follow the government's age curve that sets the relative cost for premiums in the individual market. ''Employee pay rates and raises are subject to various employment non-discrimination rules but, other than that, employers have wide discretion in setting pay,'' said Linda Mendel, a lawyer in Columbus, Ohio. It is not illegal, by the way, to discriminate in favor of older workers.

Q.

What about Zane Benefits, which is promoting a plan it says allows companies to reimburse employees who buy individual insurance with pre-tax dollars -- and even lets lower paid employees who qualify claim federal subsidies when they buy their insurance on the exchanges. How is this possible?

A.

It is not, at least according to federal regulators. The recent guidance did not mention Zane by name, but it referred to the type of plan it uses (a Section 105 plan, after that section of the tax code) and said that it, like other reimbursement plans, was subject to the Affordable Care Act's insurance market reforms but cannot comply with them because of the reimbursement mechanism. Moreover, the Labor Department declared, ''employees participating in such arrangements are ineligible for premium tax credits (or cost-sharing reductions) for Marketplace coverage.''

Zane, for its part, published its own FAQ in response to the Department of Labor FAQ. In it, Zane insisted that its plan complies with the health law and that businesses that use it can rest assured that their employees can qualify for exchange subsidies. ''This is nothing new,'' Rick Lindquist, Zane's president, wrote in an email about the Labor Department's guidance.

All of the lawyers we've talked to disagree with Zane's legal reasoning, but until one side or the other forces a resolution of the issue, it will be Zane's word against the government's.

This is a more complete version of the story than the one that appeared in print.

URL: http://boss.blogs.nytimes.com/2014/11/18/regulators-warn-against-reimbursing-employees-for-health-premiums/

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The New York Times

January 2, 2017 Monday 00:00 EST 

After Obama, Some Health Reforms May Prove Lasting

BYLINE: ABBY GOODNOUGH and ROBERT PEAR

SECTION: US; politics

LENGTH: 3523 words

HIGHLIGHT: A transformation of the delivery of health care may be an enduring legacy for the president, even as Republicans plan to repeal the Affordable Care Act.

FISHERS, Ind. - Fragments of bone and cartilage arced across the operating room as Dr. R. Michael Meneghini drilled into the knee of his first patient at a hospital here at dawn. Within an hour, the 66-year-old woman had a replacement joint made of titanium and cobalt chrome, and she was sent home the next day.

But the Obama administration was watching over her caregivers' shoulders. If, over three months, her medical costs exceeded a target amount set by President Obama's health regulators in Washington, Dr. Meneghini's employer, Indiana University Health, stood to lose money.

Such efforts to squeeze spending out of the nation's health system may well remain as Mr. Obama exits the West Wing and Donald J. Trump takes his seat in the Oval Office. The Affordable Care Act is in extreme peril, and Mr. Obama will meet with congressional Democrats at the Capitol on Wednesday to try to devise a strategy that can stave off the quick-strike repeal of the health law that Republicans plan for the opening months of the Trump administration. 

But the transformation of American health care that has occurred over the last eight years - touching every aspect of the system, down to a knee replacement in the nation's heartland - has a momentum that could prove impossible to stop.

Expanding insurance coverage to more than 20 million Americans is among Mr. Obama's proudest accomplishments, but the changes he has pushed go deeper. They have had an impact on every level of care - from what happens during checkups and surgery to how doctors and hospitals are paid, how their results are measured and how they work together.

"From the moment I first set foot in the Oval Office in February 2009, the president told me that the law can't be just about covering the uninsured, but that it also has to be about changing the way care is delivered," said Nancy-Ann DeParle, who as a White House aide helped lead the effort to pass and carry out the health law. His message, she said: "I don't want to cover everyone and just put them in the same creaky old delivery system."

Changes in the delivery system already affect far more people than the law's higher-profile coverage gains. To visit IU Health, the largest health care provider in Indiana, with 15 hospitals and 8,700 doctors, is to see those changes up close. Its leaders have started moving away from fee-for-service medicine, where every procedure, examination and prescription fetches a price. The emphasis now is on preventive care, on taking responsibility for the health of patients not only in the hospital, but also in the community.

Social work has become a larger part of the medical mission. Collaboration between doctors is becoming a necessity.

"I don't know who could be against it: higher quality and lower cost," said Ryan C. Kitchell, an executive vice president and the chief administrative officer of IU Health.

And unlike Mr. Obama's insurance coverage expansions, these changes are not in jeopardy, said Dennis M. Murphy, IU Health's president and chief executive.

"We've got to create more value in health care," Mr. Murphy said in an interview after Mr. Trump's election. "That principle, I think, survives."

During Mr. Obama's tenure, big systems like IU Health have gobbled up smaller hospitals and physician groups as the industry has consolidated, partly in response to incentives in the Affordable Care Act. Most doctors across the United States are using electronic medical records, installed in many cases with federal money provided by the economic stimulus law of 2009. The federal government and private insurers are rewarding health care providers that work together to coordinate care and avoid unnecessary expenses.

Doctors and hospitals here are obsessed with metrics, not least because under the health law, they may be rewarded or penalized based on their performance. They tally the number of medication errors, the number of patients injured in falls and the number who develop infections after certain types of surgery.

Expanding coverage is seen not as a political issue, but as a clinical and financial imperative. IU Health has more than 150 "navigators" who work with patients to help them get insurance, often through a Medicaid expansion authorized and funded by the health law and engineered here by Gov. Mike Pence, the vice president-elect.

"I've been a registered Republican my whole life, but I support the Affordable Care Act," said Dr. Gregory C. Kiray, co-chief of primary care for IU Health Physicians, "because it allows patients to be taken care of."

To better understand how Mr. Obama has changed health care, two reporters from The New York Times spent a week shadowing and talking to doctors, patients, executives and others at IU Health, a system that demonstrates the breadth of changes catalyzed by the Affordable Care Act.

To many IU Health employees, the pace of change can be bewildering, the new directives too numerous or burdensome.

"People feel like they are swimming in an ocean, drowning," said Dr. Meneghini, an orthopedic surgeon at IU Health's Saxony Hospital here in Fishers, a suburb of Indianapolis.

But the medical profession increasingly understands that painful as it is, the revolution is necessary and unstoppable.

"The national economy cannot sustain health care being as big a share of the gross domestic product as it is," Mr. Murphy said, uttering what once amounted to heresy for a health care provider.

'Be Thoughtfully Aggressive'

Fury over the Affordable Care Act helped jump-start the Tea Party movement and sweep Republicans into control of the House of Representatives in 2010 and the Senate in 2014. It ensured gridlock that stifled many of Mr. Obama's greatest legislative ambitions for six of his eight years in office, and it may well have played a role in the election of Mr. Trump, who attacked the law throughout his campaign.

Yet to Mr. Obama, the law remains one of his greatest achievements, said Denis McDonough, the White House chief of staff. It also has been his constant concern.

"This attention to cost and concern about cost, and even the emotional concern about cost, comes up all the time," Mr. McDonough said.

The Affordable Care Act gave the government sweeping authority to test new models of care, and the administration has aggressively used that power to try different ways of paying for cancer care, heart surgery, primary care and other services covered by Medicare and Medicaid.

Sylvia Mathews Burwell, who has been the secretary of health and human services since 2014, said she met with Mr. Obama early in her tenure to describe a series of payment and delivery reforms. He was so supportive, she said, that she and her team decided to undertake even more changes.

The size and speed of some of those initiatives have provoked criticism from Republicans, including Representative Tom Price of Georgia, picked by Mr. Trump to be the health and human services secretary. They say the efforts threaten the quality of care and exceed the authority of the agency overseeing Medicare by requiring doctors and hospitals to participate.

More than 170 House Republicans signed a recent letter of which Mr. Price was an author, urging the administration to "stop experimenting with Americans' health."

But moving aggressively to change how medical care is delivered and paid for has been important to Mr. Obama. In 2015, his administration set a goal for half of all Medicare payments to be tied to the quality, instead of the quantity, of care that doctors and hospitals provide by 2018. Mr. Obama believes that basing pay on whether a doctor visit or a medical procedure helps a patient, rather than on how much care the patient receives, will result in better care.

"What he said was, 'Be thoughtfully aggressive,'" Ms. Burwell said.

At Patients' Service and Mercy

"I started drinking soda again," confessed Willie Johnson, a 52-year-old patient with uncontrolled diabetes and high blood pressure.

"How much?" Dr. Michael E. Busha, a primary care physician at IU Health in Indianapolis, asked quietly as he updated Mr. Johnson's electronic record.

"Quite a bit."

For Dr. Busha, that mattered.

He helps lead the IU system's effort to measure how well doctors do at keeping patients healthy. And even this champion of "quality measures" - vital to the Obama administration's goal of paying doctors based on outcomes, not the amount of care - has found that it is not always easy to meet them.

If enough of his patients fall below the standards set by IU Health, Dr. Busha could lose some of his income. The average salary for the system's primary care doctors is $236,000. Of that, $50,000 is tied to meeting benchmarks for quality, access (whether a doctor agrees to see patients on weekends and at night, for example) and other performance measures.

Mr. Johnson, who registers patients when they arrive for neurology appointments at IU Health Methodist Hospital in Indianapolis, was not helping. He also had stopped taking his cholesterol medicine because it left a bad taste in his mouth. And he was using neither the gym membership that IU Health helps pay for nor his sleep apnea machine. "I never could get adjusted to it," he told the doctor.

Like other primary care doctors at IU Health, Dr. Busha is part of a team that includes a pharmacist, a social worker and a "care manager." Such teams, encouraged by the health law, focus on patients like Mr. Johnson who are not meeting IU Health's quality measures, and who are disproportionately likely to end up in the emergency room or be hospitalized.

"The whole paradigm now is to identify your high-risk people and provide more resources to them, provide better care to them, keep them out of the hospital," said Dr. Kiray, the primary care co-chief.

Partly because of these efforts, IU Health's two adult hospitals in downtown Indianapolis are already seeing 12 percent fewer inpatients than they were in 2013. The system is merging the two hospitals into a $1 billion medical center focused heavily on outpatient care.

President Obama would be proud. Administration officials have continually emphasized the importance of primary care and the "social determinants" of health. They have offered grants to health care providers to identify Medicaid and Medicare patients with unmet social needs: inadequate food supplies, unpaid rent or utility bills and experience with violence at home, for example.

But with some patients, only so much can be done: Mr. Johnson's care manager had stopped working with him after deciding he was not ready to make changes.

"Are we ready to try it again?" Dr. Busha asked him.

Mr. Johnson agreed to let the care manager contact him, and to return for a follow-up visit in two months.

Such efforts, said Mr. Murphy, the system's chief executive, will remain "highly relevant" even if the Affordable Care Act is repealed.

The push toward a "risk-based" model over traditional fee-for-service medicine has spread beyond Medicare and Medicaid to private insurers. And the Obama administration has been testing new ways to save money on all sorts of medical care. Some of the experiments, overseen by an office created under the Affordable Care Act, have shown promise. But evaluating results is difficult.

"It may be good in theory," Dr. John M. Thomas, a primary care physician at an IU Health practice in Lafayette, said of Dr. Busha's system of quality measurements. "But there are a lot of flaws."

For example, he explained, rather than risk being paid less because some patients have uncontrolled diabetes, doctors could tell those patients, "I'm sorry, you're not in compliance with your medications, and I don't want to be your physician."

Dr. Busha said he was used to hearing such arguments.

"I have that conversation on a weekly basis," he said. "You know: 'What if my patients don't believe in immunizations? Why am I held accountable for that?'"

He added, "We kind of tell them, 'It's your job to convince them.'"

Suddenly, Cost Counts

When IU Health discovered that a knee surgeon was using "bone cement" costing $300 a patient while another achieved the same results for $84, the first doctor was promptly informed. He switched.

IU Health now posts a color-coded "value tracker" in operating rooms that gives a green light to lower-cost surgical products, a red light to high-cost items and a yellow light to those in between.

"A huge cultural shift," Dr. Anthony T. Sorkin, the medical director of orthopedics, said of the changes in his department - for the surgeons and the patients.

The IU Health system performed 3,900 hip- and knee-replacement operations in the year that ended on June 30. But it is not enough for doctors just to replace a knee or a hip. They are under pressure, from Medicare and private insurers, to manage and coordinate care for their patients before and after surgery. And, they say, payment for their services is continually being squeezed.

Doctors have three main ways to cut costs: improve the condition of patients before surgery, look for savings in every item used in the operating room (gloves, gowns, syringes, surgical tools, sutures, sponges and the implant itself), and send patients to nursing homes that strive to shorten the length of stay.

"I've been an orthopedic surgeon for 18 years," Dr. Sorkin said. "For many of those years, I never once considered the cost for nursing homes."

Why such attention to cost? In 67 geographic areas, including Indianapolis, Medicare now sets a target price for joint-replacement procedures. That target covers not only doctor services and hospital care but also 90 days of follow-up services like physical therapy, home health care and nursing-home stays. Hospitals are at risk: Medicare can pay bonuses or impose penalties, depending on whether spending targets and quality standards set by the government are met.

"We worry about 90 days of care, 90 days of Medicare spending, not just the brief time a patient spends in the hospital," Dr. Sorkin said.

The joint-replacement program was one of the main targets of the letter that Mr. Price and other Republicans wrote to the Obama administration in September, complaining that such programs should be tested on a "voluntary, limited-scale basis" with no requirement for doctors to participate.

But in Indianapolis, the results have been promising. By working closely with nursing homes, IU Health halved the length of stay for patients recuperating from surgery, to an average of 12 days from 24 days in early 2016.

Doctors and nurses understand the need for change, but some still have concerns.

"These reforms are all intended to slow down the consumption of health care resources in the United States," said Dr. Meneghini, who is the director of joint-replacement at Saxony Hospital here in Fishers. "We are careening at a rapid rate to a two-tier system. The public who can't afford it goes to a public hospital and gets free health care. Those who have money get to pay for really nice care."

A Mind Unchanged

Justin Kloski learned that he qualified for Medicaid under the worst of circumstances. The student and part-time lawn-company worker had lost 20 pounds, could not shake a nagging cough and was sleeping 14 hours a day when he decided to visit a clinic in Muncie, Ind., that provides free care for the poor and uninsured. A clinic employee invited Mr. Kloski, now 28, to apply for Medicaid.

A few days later, he took his new coverage to the emergency room at IU Health Ball Memorial Hospital in Muncie. A CT scan found a 15-centimeter tumor in his chest, so big it was pressing on his windpipe. In May 2015, he learned he had Hodgkin's lymphoma, a form of cancer that is curable if caught early.

The Affordable Care Act, and Governor Pence's decision to go against many other Republican governors and expand Medicaid under the law, may well have saved Mr. Kloski's life.

He is among more than 400,000 Indiana residents - many of them previously uninsured - who have enrolled in Medicaid since Mr. Pence expanded it in 2015, the 10th Republican governor to do so. Under the terms of the health law, anyone with income up to 138 percent of the poverty level, or approximately $16,500 a year for an individual, now qualifies in states that opt to expand the program.

IU Health says it receives more Medicaid payments than any other health care provider in the state. Since the expansion began, the percentage of patients with Medicaid has grown to 23.2 from 20.7.

At the same time, the percentage of IU Health patients who are uninsured has fallen to 2.2 from 5.

In 2015 alone, the health system enrolled 14,000 people in Medicaid or private coverage, sometimes even signing up patients as they lay in hospital beds.

"We went all in because it's a pretty big deal to us," said Jonathan W. Vanator, IU Health's vice president for revenue cycle services.

In the first nine months of last year, IU Health officials said, the amount of bad debt owed by patients and referred to collection agencies totaled $233 million, a 23 percent reduction from the comparable period in 2015, thanks largely to Mr. Obama's health law.

But, the officials added, these gains have been largely offset by cuts in Medicare reimbursements and other federal funds under a law that has given and taken away.

Mr. Murphy is among many hospital executives now anxious about the possibility of seeing a bump in uninsured patients if the health law is repealed, while not getting back the federal funds they gave up under the health law. "I do think it would be problematic if part of the deal was changed and not the whole deal," he said.

Mr. Pence expanded Medicaid only after the Obama administration agreed to let Indiana do it in its own way: Instead of getting virtually free coverage, as Medicaid recipients in many other states do, people enrolled in Indiana's expansion pay up to 5 percent of their income toward it. Mr. Trump appears interested in promoting Indiana's "personal responsibility" model: He has picked its chief architect, Seema Verma, to run the Centers for Medicare and Medicaid Services.

Since Mr. Kloski had no income when he enrolled, he paid $1 a month; he has since been classified as "medically frail" and does not have to pay anything.

Medicaid has paid for virtually all of his cancer care, including a one-week hospitalization after the diagnosis, months of chemotherapy, and frequent scans and blood tests.

But Mr. Kloski and his mother, Renee Epperson, are still not fans of the health law over all. They believed that it required that Mr. Kloski be dropped, when he turned 26, from the health plan his mother has through her job at Target - not understanding that it was the law that kept him on the plan until he was 26.

Mr. Kloski paid a penalty for going uninsured in 2014 rather than even explore whether he might qualify for a subsidy and find an affordable private plan through the marketplaces.

"There were so many horror stories about how expensive it was going to be," Ms. Epperson, 47, recalled. "Justin said, 'I'm not even going to try it, Mom.'"

And until they were interviewed for this article, the mother and son did not know that the law was responsible for the expansion of Medicaid that Mr. Kloski benefited from. Neither voted in last year's presidential election; Ms. Epperson said that she disliked both candidates, and that even though Hillary Clinton supported the Affordable Care Act, she found Mrs. Clinton's positions unacceptable on too many other issues, like abortion rights, to support her.

Still, she said, she ardently hopes that Mr. Trump and the Republican Congress will continue allowing low-income adults like her son to qualify for Medicaid.

"Oh my God, yes," she said. "Absolutely."

As for Mr. Murphy, IU Health's chief executive, he said that while he did not want to think too much about changes that were still hypothetical, the prospect of losing the Medicaid expansion made him anxious.

"I worry about lots of things," he said. "That list is probably 50 long, and this is definitely on that list."

Get politics and Washington news updates via Facebook, Twitter and in the Morning Briefing newsletter.

Gardiner Harris contributed reporting.

PHOTOS: President Obama at the White House after signing the Affordable Care Act into law in March 2010. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES) (A12); At right, Dr. R. Michael Meneghini, left, performing a partial knee replacement at a hospital in the Indiana University Health system. (A12-A13); Lindsay Ehrgott is trained to help patients at IU Health Methodist Hospital sign up for health care if they are not already covered.; Justin Kloski, who has Hodgkin's lymphoma, showing the port on his chest for treatments. Medicaid has paid for virtually all of his cancer care. (PHOTOGRAPHS BY ILANA PANICH-LINSMAN FOR THE NEW YORK TIMES); Protesters gathered in Washington in anticipation of a United States Supreme Court ruling on the health care overhaul law in June 2012. (PHOTOGRAPH BY BRENDAN HOFFMAN FOR THE NEW YORK TIMES) (A13)

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HIGHLIGHT: Richard Mourdock preacts to the Supreme Court's health care ruling.

When a politician responds to something another politician has not yet said, we call that a "prebuttal." It's a variant is the "presponse," in which networks air the opposition party's "response" to a State of the Union Address that was taped prior to delivery.

Richard Mourdock, the Tea Party favorite who defeated Senator Richard Lugar of Indiana in the Republican primary in May, is fine-tuning another "pre" category, the "preaction."

Mr. Mourdock taped responses to several possible outcomes of the Supreme Court ruling on the constitutionality of the Affordable Care Act - the court upholds the law, the court overturns it, the court splits, the court doesn't provide an answer.

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The New York Times

June 26, 2015 Friday  
Late Edition - Final

Ruling Elicits Sighs of Relief and Vows to Continue Fighting

BYLINE: By ABBY GOODNOUGH and SABRINA TAVERNISE; Jonathan Weisman and Jackie Calmes contributed reporting.

SECTION: Section A; Column 0; National Desk; Pg. 17

LENGTH: 938 words

WASHINGTON -- Democrats said it was finally time to accept that the Affordable Care Act was here to stay. Republicans vowed to keep trying to get rid of the law, but conceded that at this point, their best chance would be by winning back the White House next year.

And people like Margaret McElwain, who has breast cancer and a part-time job at Target, exulted over the Supreme Court's decision to allow health insurance subsidies to keep flowing to more than six million Americans in the 34 states that did not establish their own online insurance marketplaces under the law.  

''Thank God,'' said Ms. McElwain, 64, of Mooresville, N.C., who was on her way to a chemotherapy appointment when she heard about the ruling. She said she pays $96 a month for the Blue Cross Blue Shield plan that she bought through the federal insurance marketplace, and receives a subsidy of more than $700 to cover the rest. ''I really did not know how it was going to turn out, and you cannot imagine my relief.''

Hospitals and health centers across the country were breathing a sigh of relief.

''A catastrophe just got stopped,'' said Dr. Gary Wiltz, an internist who runs a network of community health centers in rural Louisiana. He said his clinics have been able to increase diagnosis and treatment of diabetes and hypertension, two chronic illnesses that hit particularly hard among low-income Americans. ''We have people in the middle of cancer treatments, some being worked up for heart disease. If that insurance would have gone away, it would literally have been a path to early death.''

In Congress, the court's decision left Republicans badly divided on their next move. If the court had sided with the plaintiffs, they had hoped to force President Obama to negotiate a new set of health care reforms more to their liking. Now, any significant legislation will simply be vetoed, they conceded. That leaves them with a decision: Try to do something modest that could overcome a veto, or press forward with an attempt to truly replace the Affordable Care Act?

House Republicans vowed to press forward. But Senate Republican leaders did not appear to share their House colleagues' enthusiasm for continuing to go after the health care law.

''We know the president's not likely to sign anything we send him, and the Democrats are not likely to vote for anything we send him,'' Senator Mitch McConnell, the majority leader, said in an interview. ''So it leaves only one vehicle available, if you want to revisit Obamacare, and that would be to use reconciliation. But no decision has been made on the timing of that.''

Mr. McConnell was referring to an obscure budget rule under which Republicans could make changes to the Affordable Care Act that cannot be filibustered in the Senate -- but only if the changes were about spending and revenue provisions.

In truth, many Republican elected officials were likely relieved, despite their stated opposition to the law, to not have to deal with the fallout of a ruling that would have stripped more than 6.3 million people of subsidized health insurance. Many of those who stood to lose subsidies -- and likely their insurance, which would have proved unaffordable without them -- are Southern working-class whites, on whom Republicans tend to rely for support. About 61 percent of the people who would have become uninsured are white, according to an Urban Institute analysis in January, and about 62 percent live in the South.

Most Republican governors reaffirmed their opposition to the health care law in statements reacting to the decision. But a handful, including Gov. Bill Haslam of Tennessee, had something positive to say. Mr. Haslam tried to expand Medicaid under the health law this year but was rebuffed by his fellow Republicans in the state legislature.

''I am pleased for those folks who have insurance subsidies,'' Mr. Haslam said of the ruling. ''While philosophically I didn't agree with their ruling, in terms of the smoothness of the market and people obtaining coverage in a predictable way, I think that's a good thing.''

More typical was the response from Gov. John Kasich of Ohio, a likely Republican presidential candidate.

''The law has driven up Ohio's health insurance costs significantly,'' he said, ''and I remain convinced that Congress should repeal it and replace it with something that actually reduces costs.''

Polls suggest that Americans remain sharply divided in their opinion of the law, and for some, like Kevin Archer of Tampa, Fla., who gets health insurance through his job selling advertising for newspapers, the ruling was a disappointment.

''I'm very much against it,'' he said of the law. ''It's negative for the country. I don't have the freedom not to buy health care.''

Hospital executives in the 34 states that rely on the federal marketplace, many of who saw drops in uncompensated care costs because of the Affordable Care Act, were among those expressing relief.

''It just sort of creates this huge safety net for all of us, knowing that, when patients come in, there will still be some reimbursement,'' said Meri Armor, the chief executive officer of Le Bonheur Children's Hospital in Memphis.

Also excited was Jimmy Lewis, a 44-year-old concession stand worker in Jackson, Miss. Mr. Lewis said he paid $35 a month for his midlevel silver plan and a subsidy covered the rest. He said he is generally healthy, but has back and tooth problems and is relieved he will still be able to afford his insurance.

''Great, that's great,'' Mr. Lewis said. ''I can't believe it! I really didn't think it was going to hold.''

URL: http://www.nytimes.com/2015/06/26/us/politics/health-law-ruling-elicits-sighs-of-relief-and-vows-to-continue-fighting.html

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April 13, 2012 Friday  
Late Edition - Final

Cuomo Acts To Advance Health Law In New York

BYLINE: By THOMAS KAPLAN

SECTION: Section A; Column 0; Metropolitan Desk; Pg. 23

LENGTH: 956 words

ALBANY -- Gov. Andrew M. Cuomo, stepping into the national debate over President Obama's health care law, used his executive power on Thursday to carry out one of its critical features in New York after the state's Republican lawmakers blocked legislation to do so.

Mr. Cuomo, a Democrat who has generally avoided national politics even as he is often mentioned as a potential candidate for president, offered an enthusiastic endorsement of the benefits of the health care measure, which is currently being litigated before the Supreme Court and contested in this year's presidential campaign. 

As he issued an executive order to establish a health insurance exchange, an online marketplace where individuals and small businesses can choose among competing health insurance plans, Mr. Cuomo said it would drive down the cost of insurance while helping the 2.7 million uninsured New Yorkers get affordable coverage.

''The bottom line,'' Mr. Cuomo said in a statement, ''is that creating this health exchange will lower the cost of health insurance for small businesses, local governments and individual New Yorkers across the state.''

For nearly a year, Mr. Cuomo asked the Legislature to set up the exchange. But the Republican majority in the State Senate refused to consider the measure, arguing that approving the exchange would amount to condoning the law, the Affordable Care Act, which they deride as Obamacare.

The Senate Republicans also cited the uncertainty surrounding the health care law, given the Supreme Court challenge, and last month, they blocked Mr. Cuomo from including the exchange in the state budget for the fiscal year that began April 1.

The health care law requires each state to put an insurance exchange in place by 2014, and gives the federal government the power to do so in states that do not act on their own.

Mr. Cuomo, unable to win support for the exchange in the State Senate, vowed to move ahead unilaterally, and on Thursday, he signed the order to set up the exchange within the State Health Department, rather than as a separate state entity, as his original legislation had sought to do.

Mr. Cuomo's order drew praise on Thursday from Democratic lawmakers, health advocacy groups and leaders in the state's health care industry. Kenneth E. Raske, the president of the Greater New York Hospital Association, called the move ''a way of alleviating the current crisis facing those that don't have access to care because of lack of insurance.''

But Mr. Cuomo's move irked some conservatives, who are determined to fight the health care law and view state capitals as important battlegrounds in which the law's implementation can be contested.

State Senator Gregory R. Ball, Republican of Putnam County, who has been one of the most vocal critics of the health exchange proposal, said Mr. Cuomo was acting prematurely, given the Supreme Court case. Mr. Ball also criticized the governor for ''sidestepping the Legislature'' to set up the exchange.

''Enlisting our state in a program that may cease to exist on both constitutional and administrative grounds is, in my opinion, overly aggressive and fundamentally imprudent,'' Mr. Ball said.

Michael F. Cannon, the director of health policy studies at the Cato Institute, a libertarian research center in Washington, said that refusing to pass legislation to set up a health exchange was ''the most powerful blow that a state can strike against Obamacare,'' and questioned Mr. Cuomo's use of an executive order.

''King Andrew shouldn't be out creating new bureaucracies on his own,'' Mr. Cannon said. ''If the people's elected representatives say they don't want to create a new government bureaucracy, then the government doesn't have the power to create a new government bureaucracy.''

Since the passage of the Affordable Care Act, 11 states have set up insurance exchanges, according to the National Conference of State Legislatures. Ten did so with legislation; only one -- Rhode Island -- used an executive order, and a lawsuit challenging the authority of that order is pending.

Mr. Cuomo's office defended the use of an executive order, noting that the state would rely on federal financing to set up the exchange, rather than any new state spending, and that it would not set up a new governmental body. New York has already received $88 million in federal grants to plan for its health exchange; setting up the exchange will allow the state to seek additional federal financing.

''The activities that are necessary to implement the exchange are within the existing legal authority of the Department of Health, in which it will be based, and the other agencies with which it will work, including the Department of Financial Services,'' Mr. Cuomo's counsel, Mylan L. Denerstein, said in a statement.

Peter J. Kiernan, who served as chief counsel for former Gov. David A. Paterson, a Democrat, said that although ''legislation is always optimal,'' he believed the executive order was legal.

''In essence, he's telling the Department of Health, which works for him, to get ready to do this, and to use federal money that has already come through,'' Mr. Kiernan said. ''There may be people that would complain about it, but I don't think that anyone would be successful challenging the governor's authority here.''

A spokesman for the Senate Republicans declined to comment on the executive order. But after Mr. Cuomo said last month that he would set up the exchange using his own power, the Senate majority leader, Dean G. Skelos, a Long Island Republican, said the Senate Republicans would not be interested in challenging such a move.

''The governor has the right to issue executive orders,'' Mr. Skelos said. Still, he added, ''If somebody wants to sue him, fine.''

URL: http://www.nytimes.com

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November 5, 2013 Tuesday  
Late Edition - Final

Strategic Move Exempts Health Law From Broader U.S. Statute

BYLINE: By ROBERT PEAR; Jackie Calmes contributed reporting.

SECTION: Section A; Column 0; National Desk; Pg. 12

LENGTH: 1170 words

WASHINGTON -- The Affordable Care Act is the biggest new health care program in decades, but the Obama administration has ruled that neither the federal insurance exchange nor the federal subsidies paid to insurance companies on behalf of low-income people are ''federal health care programs.''

The surprise decision, disclosed last week, exempts subsidized health insurance from a law that bans rebates, kickbacks, bribes and certain other financial arrangements in federal health programs, stripping law enforcement of a powerful tool used to fight fraud in other health care programs, like Medicare.

The main purpose of the anti-kickback law, as described by federal courts in scores of Medicare cases, is to protect patients and taxpayers against the undue influence of money on medical decisions. 

Kathleen Sebelius, the secretary of health and human services, disclosed her interpretation of the law in a letter to Representative Jim McDermott, Democrat of Washington, who had asked her views. She did not explain the legal rationale for her decision, which followed a spirited debate within the administration.

Under the Affordable Care Act, millions of people will be able to buy insurance from ''qualified health plans'' offered on exchanges, or marketplaces, run by the federal government and by some states.

Most of the buyers are expected to be eligible for subsidies to make insurance more affordable. The subsidies, paid directly to insurers from the United States Treasury, start in January and are expected to total more than $1 trillion over 10 years.

Ms. Sebelius said the Health and Human Services Department ''does not consider'' the subsidies to be federal health care programs. She reached the same conclusion with respect to federal and state exchanges, built with federal money, and with respect to ''federally funded consumer assistance programs,'' including the counselors, known as navigators, who help people shop for insurance and enroll in coverage through the exchanges.

The federal exchange has been plagued with problems since it opened on Oct. 1. The Obama administration said that the online enrollment system for the exchange was out of service again for 90 minutes on Monday afternoon in an ''unscheduled outage.'' That was in addition to the scheduled down time from 1 a.m. to 5 a.m. each day.

President Obama, speaking at a political event on Monday night, said he was determined to fix the problems that have frustrated millions of people trying to use the website for the federal exchange.

''When the unexpected happens, when the unanticipated happens, we're just going to work on it,'' Mr. Obama said. ''We're going to fix things that aren't working the way they should be. We're going to smooth this thing out, and we're just going to keep on going.' ''

Lawyers and law enforcement officials said Ms. Sebelius's decision was unexpected because the insurance exchanges and subsidy payments appeared to fit the definition of federal health care programs in the anti-kickback statute.

Generally, the law makes it a crime to pay or receive anything of value in return for the referral of patients or as an inducement for people to buy goods and services reimbursed by federal health care programs. Such programs are defined broadly as ''any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States government.''

''The secretary's decision will have some very significant consequences,'' said D. McCarty Thornton, former chief counsel to the inspector general at the Health and Human Services Department. ''The federal anti-kickback statute will, in most cases, not apply to subsidized health plans or the items and services furnished by those plans.''

''Plans and providers are very happy to be relieved of that concern,'' Mr. Thornton added.

Kevin G. McAnaney, a lawyer who specializes in health care fraud and abuse cases, said Ms. Sebelius's decision would allow drug companies to give coupons to people who buy insurance through the exchanges.

Such coupons subsidize co-payments and reduce out-of-pocket costs for consumers, encouraging them to use certain brand-name prescription drugs when lower-cost alternatives are available, Mr. McAnaney said.

The federal government has forbidden the use of drug coupons in Medicare and other federal health programs, saying they amount to a classic kickback scheme, with drug companies paying consumers to use their products.

Mark Merritt, the president of the Pharmaceutical Care Management Association, which represents benefit managers like Express Scripts and CVS Caremark, expressed a similar concern. ''The coupons steer consumers away from lower-cost alternatives to more expensive drugs, increasing costs to insurers and to the government,'' he said.

Coupons may drive down the co-payment for an expensive brand-name drug, but often, the insurer must pay much more than it would for a generic version of the medication.

Some drug companies and their lawyers had assumed that federal insurance subsidies were part of a federal health care program.

Drug coupons offered by Merck, for example, say that they are not valid for patients covered by Medicare, Medicaid or ''any qualified health plan purchased through a health insurance exchange established by a state government or the federal government.''

In a vivid demonstration of how the anti-kickback law can be applied, the Justice Department announced on Monday that Johnson & Johnson would pay more than $2.2 billion to resolve criminal and civil investigations. The government said the company had, among other things, paid kickbacks to doctors and nursing home pharmacies to promote the use of certain drugs. The company said the payments were ''lawful rebates.''

The National Health Council, which represents patients and drug companies, praised Ms. Sebelius's decision. ''People with chronic diseases and disabilities will be able to continue using co-payment assistance programs,'' said Myrl Weinberg, the chief executive of the council.

Ms. Sebelius may not have the last word, lawyers said. A whistle-blower could file suit under the False Claims Act, charging that health care providers, health plans or drug makers had defrauded the government, and a federal court might then decide whether the federal exchange or subsidy payments were federal health care programs.

Addressing a rally of supporters on Monday, Mr. Obama responded to critics who say he has broken his promise that people could keep their health insurance if they liked it.

Mr. Obama provided some additional explanation: ''Now if you have or had one of these plans before the Affordable Care Act came into law and you really liked that plan, what we said was you could keep it if it hasn't changed since the law was passed.''

In recent weeks, hundreds of thousands of people have received notices discontinuing individual insurance policies because they did not meet minimum coverage standards under the health care law.

URL: http://www.nytimes.com/2013/11/05/us/politics/federal-health-law-may-not-be-a-federal-health-care-program.html

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GRAPHIC: PHOTO: President Obama discussed the Affordable Care Act at a dinner in Washington. The administration has ruled that it is not subject to a specific anti-fraud law. (PHOTOGRAPH BY DOUG MILLS/THE NEW YORK TIMES)

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March 30, 2012 Friday

Reporter Q. and A. on the Health Care Arguments

BYLINE: THE NEW YORK TIMES

SECTION: US; politics

LENGTH: 119 words

HIGHLIGHT: Reed Abelson and Adam Liptak of The Times answered readers' questions about the health care arguments in the Supreme Court.

On The Times's Facebook page on Thursday, Adam Liptak, the newspaper's Supreme Court correspondent, and Reed Abelson, a reporter covering health care for the Business Day section, hosted a discussion with readers about the legal battle over the Patient Protection and Affordable Care Act. Below is a transcript of highlights from the question-and-answer session.

[View the story "Facebook Q & A on Supreme Court Arguments" on Storify]

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The New York Times

June 26, 2015 Friday  
Late Edition - Final

Court Ruling Seen as a Spur to Consolidation of Insurers

BYLINE: By MICHAEL J. de la MERCED

SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1

LENGTH: 771 words

A new round of consolidation in the health insurance industry appeared closer as companies seek to grow larger, driven in part by cost-cutting and opportunities that are part of the Affordable Care Act.

In the latest jockeying, Humana, the smallest of the big five insurers, is pursuing a deal to sell itself and could reach an agreement by next week, according to a person briefed on the matter, who spoke on the condition of anonymity. Among those in the running to buy it are two bigger competitors, Aetna and Cigna.

The machinations of Humana -- set against a backdrop of frenzied merger discussions within the insurance industry -- received an extra jolt from the Supreme Court's ruling on Thursday that the government could furnish tax subsidies for poor and middle-class Americans to buy health insurance. 

The long-awaited ruling, in the case King v. Burwell, was a major victory for the Obama administration that will greatly benefit large parts of the American health care system. Insurers, especially, had been counting on those billions of dollars in tax subsidies to draw in new customers, particularly as Medicare and Medicaid turn to private health plans to offer coverage. Many insurers, including Humana, issued statements in support of the court's decision.

Investors, too, were heartened by the ruling as shares in the major health insurers jumped on Thursday after the Supreme Court announced its decision. Trading in Humana's stock was briefly halted and its price gained more momentum after Bloomberg News reported that it was near a deal to sell itself.

Still, it remains to be seen whether government regulators will bless too many consolidations, because of antitrust concerns. And it is unclear what effect more mergers will have on the prices consumers pay for insurance.

Other parts of the American health care sector were also bolstered by the ruling, particularly hospitals, which are expected to benefit from an increase in paying customers who now are covered by Medicaid or subsidized private insurance. Shares in HCA Holdings, the huge hospital operator, rose nearly 9 percent, while those of Tenet Healthcare jumped 12 percent.

Affirmation for a signature feature of the Affordable Care Act will make firm for some time the ability of insurers to move into new markets. Yet insurers have also faced pressure to cut their costs, especially since these new customers are more sensitive to the price of health coverage.

That has propelled merger talks within the health insurance industry of an intensity unseen for the last several years, as companies vie to find the right partner and the kind of scale that will enable them to reduce costs and gain more negotiating power with health systems.

Insurers are also seeking deals with a sense of urgency, lest they risk being left out if government regulators limit the number of mergers that will be allowed to happen.

Already, Anthem has offered $47 billion to acquire Cigna, a deal that Cigna has rebuffed, potentially with an eye to buying Humana. Anthem itself had also expressed interest in buying Humana, though it is now focused on Cigna.

And UnitedHealthcare, the biggest of the health insurers, has made a preliminary approach for Aetna, people briefed on the matter said previously.

Humana, based in Louisville, Ky., is seen as attractive because of its big presence in the Medicare market, which has benefited from the Affordable Care Act. Aetna, Anthem and Cigna all have relatively smaller Medicare Advantage businesses.

But Humana has struggled to meet Wall Street's profit expectations for much of the last year, though it enjoyed rises in both its membership rolls and its revenue in the first three months of the year.

The company has been working with bankers at Goldman Sachs to sift through its potential deal options, fielding expressions of takeover interest from a number of suitors.

While Humana is perhaps the least expensive takeover target within the big five insurers, with a market value of $27.6 billion, it faces a few distinct issues.

Among them is that its rival with the biggest financial resources to pursue a transaction, UnitedHealthcare, would most likely be barred by government regulators because both companies have major operations tied to Medicare.

With UnitedHealthcare and Anthem both pursuing two of the most logical buyers of Humana, the smallest insurer risked being left alone -- and competing against far bigger rivals -- if it did not strike its own deal ahead of other potential transactions.

Representatives for Humana, Aetna and Cigna were not immediately available for comment.

URL: http://www.nytimes.com/2015/06/26/business/dealbook/humana-said-to-pursue-sale-as-courts-ruling-gives-insurers-a-lift.html

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The New York Times

March 30, 2016 Wednesday  
Late Edition - Final

Policyholders Under Law Prove Sicker and Costlier

BYLINE: By ROBERT PEAR

SECTION: Section A; Column 0; National Desk; Pg. 14

LENGTH: 684 words

WASHINGTON -- People newly insured under the Affordable Care Act were sicker, used more medical care and had higher medical costs than those who already had coverage, the Blue Cross and Blue Shield Association said Tuesday in a new study of its policyholders.

Because insurers' premiums have to cover their medical expenses, the new report helps explain why Blue Cross plans have sought, and insurance commissioners have approved, substantial rate increases in many states. Another round of rate review is about to begin, with insurers generally required to file rate requests for 2017 in the next two months.  

The findings are noteworthy because Blue Cross and Blue Shield plans operate across the country and have the largest share of the individual market in many states, giving them an unrivaled source of claims data.

In its report, the Blue Cross and Blue Shield Association examined the use of medical services by people who enrolled in its plans before and after major provisions of the Affordable Care Act took effect in 2014.

One of those provisions essentially required insurers to offer coverage to people who had previously been denied coverage because of their medical problems.

People newly enrolled in individual Blue Cross health plans in 2014 and 2015 were found to have higher rates of certain diseases and conditions, including high blood pressure, diabetes, depression, coronary artery disease, H.I.V. and hepatitis C, than people who already had coverage.

Diabetes was nearly twice as common among newly enrolled consumers as among those previously enrolled, the report said. Hepatitis C was more than twice as common, and H.I.V. was more than three times as common, it said.

Likewise, the report said, consumers newly enrolled in Blue Cross plans in 2014-15 used more medical services than those who first bought coverage before 2014. Hospital admission rates were 84 percent higher, it said, and the frequency of visits to doctors and other medical professionals was 26 percent higher.

Blue Cross said the study was based on claims for 4.7 million people. About one-third had been continuously enrolled since 2013; the others signed up in 2014 or 2015.

Administration officials said the study showed the need for the health care law, signed six years ago by President Obama. ''It's no surprise that people who newly gained access to coverage under the Affordable Care Act needed health care,'' said Ben Wakana, a spokesman for the Department of Health and Human Services. ''That's why they were locked out of coverage before.''

Alissa Fox, a senior vice president for the Blue Cross and Blue Shield Association, said the differences in the prevalence of disease could narrow as newly insured consumers receive care and medications to prevent and treat illnesses. Blue Cross companies have programs to help consumers ''get healthy faster and stay healthy longer,'' she said.

New insurance policies are often more generous and comprehensive than individual policies sold before the health care law. The new policies must, for example, cover maternity care and mental health and substance abuse services.

Some of the people buying insurance under the health care law come from states' ''high-risk pools,'' created specifically for people with cancer, heart disease or other serious medical problems.

In rate requests filed with state regulators in the last two years, many insurers said they had been aware of a pent-up demand for health care, but had underestimated how much care their new customers would require.

Researchers and health policy experts had predicted that people with higher medical costs would enter the market in the first few years of the public insurance exchanges. And the health care law provided special payments to insurers with unexpectedly high costs.

Federal and state officials and consumer advocates said they hoped that premiums would become more stable and predictable in the next couple of years.

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URL: http://www.nytimes.com/2016/03/30/us/politics/newest-policyholders-under-health-law-are-sicker-and-costlier-to-insurers.html

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The New York Times Blogs
(Economix)

September 27, 2013 Friday

A Health Care Fight That Punishes Federal Workers

BYLINE: UWE E. REINHARDT

SECTION: BUSINESS; economy

LENGTH: 1753 words

HIGHLIGHT: The Affordable Care Act was not intended to deny a employer contribution to Congressional employees’ health coverage, and accusations that Congress is acting hypocritically in sponsoring such coverage are unfounded, an economist writes.

Updated | to clarify the contentions of critics about the law's application to Congressional staff members, and with a postscript correcting the legislative history of the Grassley amendment.

Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.

One can think of the Affordable Care Act as a highly complex patch on the even more complex and fragmented health insurance system.

Thinking of it that way helps explain why even people who have no ideological dog in the hunt have such difficulty getting their mind around this complex legislation, especially from a worm's-eye view. It does not help that Americans are bombarded daily with misleading information about the act.

Viewing the law from a distance, one discerns two main objectives: 

1. To facilitate easier and affordable access to health insurance to Americans who do not now have health insurance (and that latter phrase warrants emphasis).

2. To help reorganize the delivery of health care in the United States to enhance its cost-effectiveness by lowering the cost of producing a given level or quality of care or by enhancing the quality of care for a given cost, or both.

To the best of my knowledge, nowhere in its many pages does the law, either in its spirit or its wording, suggest that any employer - including the federal government - who currently sponsors health insurance for its employees and who makes contributions to the premiums for that coverage may no longer do so come Jan. 1.

And yet, some maintain that the law forces the federal government to drop such coverage for certain employees. Among them are the editors of , Michael Cannon of the libertarian Cato Institute and Robert Moffitt, Edmund Haislmaier and Joseph Morris of the Heritage Foundation.

These longstanding critics of the Affordable Care Act assert that its Section 1312(d)(3)(D) prevents the federal government from sponsoring health insurance for members of Congress and their staffs; they accuse the Office of Personnel Management of the Obama administration of breaking the law by exempting the targeted federal employers from this provision. Writing on the opinion page of The Wall Street Journal, for example, former Secretary of Education William Bennett and Christopher Beach speak of "The Hypocrisy of Congress's Gold-Plated Health Care."

Traditionally, members of Congress and all federal employees have been able to choose their private health insurance coverage from a wide array of policies offered by private health insurance on a federal health insurance exchange, the Federal Employee Health Benefits Program, operated by the Office of Personnel Management of the executive branch.

The premiums on this exchange have for decades been fully community-rated, as they are within companies under most employment-based health insurance systems, certainly among large employers. This means the premium quoted by a particular insurer was the same for every individual (and analogously for families), regardless of the health status or age of the insured.

The federal government has contributed to coverage of members of Congress and of all federal employees 72 percent of the average premium bid made by the various insurers on the exchange, or 75 percent of the premium of the health policy chosen by the employee, whichever is lower.

Most large private-sector employers make similar contributions, albeit a bit more generous, toward coverage for their employees. In that regard, the federal program is not really "gold-plated coverage" as Mr. Bennett and Mr. Beach suggest.

Effective Jan. 1, Section 1312(d)(3)(D) of the law forces members of Congress and their personal staff out of the exchange and onto the state-run or federally run, state-based health insurance exchanges established under the law, there to seek whatever coverage is offered on the relevant exchange.

These new exchanges, it must be emphasized, were not even intended for the great majority of employed Americans and their families who already have job-based, group health insurance with premiums that are community-rated within the company (although some smaller employers currently with small-group coverage and those with many low-wage workers may in the future take advantage of the federal subsidies offered on the new exchanges).

Rather, the new exchanges were designed mainly for the minority of Americans who have to buy coverage in the nongroup market, many millions of whom have pre-existing medical conditions and hitherto could not afford the high premiums they were quoted or were refused coverage outright.

For what it is worth, I view the requirement spelled out in Section 1312(d)(3)(D) as dubious, because it will create many avoidable headaches regarding the interface with Medicare and the Internal Revenue Service. To get a feel for these headaches, I refer readers to a lucid column written by Prof. Timothy Jost of the Washington and Lee School of Law on Aug. 7 and posted on the Health Affairs blog.

It may be helpful to present the relevant Subsection D of Section 1312(d)(3)(D), or the more intrepid can read the entire Section 1312 (starting on Page 64). Subsection D reads as follows:

(D) MEMBERS OF CONGRESS IN THE EXCHANGE.
(i) REQUIREMENT. Notwithstanding any other provision of law, after the effective date of this subtitle, the only health plans that the Federal Government may make available to members of Congress and congressional staff with respect to their service as a member of Congress or congressional staff shall be health plans that are:

(I) created under this act (or an amendment made by this act); or
(II) offered through an exchange established under this act (or an amendment made by this act).

(ii) DEFINITIONS. In this section:

(I) MEMBERS OF CONGRESS. The term "member of Congress" means any member of the House of Representatives or the Senate.
(II) CONGRESSIONAL STAFF. The term "congressional staff" means all full-time and part-time employees employed by the official office of a member of Congress, whether in Washington, D.C., or outside Washington, D.C.

That's it. Does it state in the section that the federal government may not continue to make the traditional employer-provided contributions to the targeted employees' health insurance?

As I read this short section, it says absolutely nothing about this issue, and I am by no means the first to assert this. Indeed, as early as April 2010, about a month after the act was signed into law on March 23, 2010, the legal staff of the nonpartisan Congressional Research Service, Congress's research arm, came to a similar conclusion in response to an inquiry on this point from Representative Tom Price, Republican of Georgia.

The legislative attorneys composing the carefully worded memo suggested to Mr. Price that the intent of the law was not to forbid the government from making contributions to the insurance coverage of the federal employees covered by the section. But they looked to the relevant federal agency to clarify the questions raised by Section 1312(d)(3)(D).

It may be asked how this dubious section ever found its way into the law. The idea of requiring Congressional employees to take part in the new exchanges was included in by an amendment proposed by Senator Charles Grassley, Republican of Iowa - but his amendment, unlike the final version, provided for the employer contributions to be maintained. (See the postscript below.)

Years ago, former Representative Pete Stark, Democrat of California, somewhat facetiously introduced a bill in the House of Representatives providing that all members of Congress should lose their employer-based insurance coverage until they had legislated a truly universal health insurance system in this country.

We now have the spectacle of Senators David Vitter, Republican of Louisiana, and Ted Cruz, Republican of Texas, eagerly seeking to abolish employer-based coverage for their colleagues and, if Senator Cruz has his way, for all personnel on the federal government's payroll, because Congress had tried at long last to extend insurance coverage to more Americans.

It would all be quite amusing, were it not so serious an issue.

Postscript

Comments submitted on my post have suggested that it was unfair to Senator Grassley, because in his own amendment to the bill eventually passed by the Senate he had anticipated the conundrum that has now emerged on Section 1312(d)(3)(D). It is a fair criticism. I accept it.

As the thorough legislative analysis for the Heritage Foundation by Messrs. Moffit, Haislmaier and Morris points out, the ultimate wording was not from Senator Grassley's amendment, which made explicit mention of the federal contribution toward health insurance of Congressional employees and members of Congress, as did a version approved by the Senate Finance Committee.

In subsequent legislative maneuvering (and despite Senator Grassley's efforts), this provision was unfortunately omitted, as it might have avoided the uncertainly on this point. (The final language was similar to an amendment by Senator Tom Coburn, an Oklahoma Republican, that was in the version reported out by a different Senate committee.)

In the absence of language like Senator Grassley's, Messrs. Moffit, Haislmaier and Morris state that under Chapter 89 of Title 5 of the U.S. Code, the government lacks the statutory authority to make employer contributions toward the health insurance of federal employees and members of Congress outside the Federal Employees Health Benefits Program.

In its own analysis of Section 1312(d)(3)(D), however, the Congressional Research Service suggested that "it seems that the section may provide the authority for the federal government to make a contribution to the health insurance premiums of Members of Congress." This analysis does not mention any conflict with Chapter 89 of Title 5 of the U.S. Code.

My own sense in this case is that it was not the spirit of the Affordable Care Act - nor Senator Grassley's intent - to pre-empt the federal contribution toward Congressional employees' health insurance. So to accuse Congress of a hypocritical carve-out over an issue that had best be viewed as sloppy legislation is not warranted, which was the main point of my post.

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February 5, 2015 Thursday  
Late Edition - Final

G.O.P. Lawmakers Propose Alternative to Obamacare

BYLINE: By ROBERT PEAR

SECTION: Section A; Column 0; National Desk; Pg. 18

LENGTH: 926 words

WASHINGTON -- Three influential Republican members of Congress unveiled a comprehensive proposal on Wednesday to replace President Obama's health care overhaul with an alternative that would halt the expansion of Medicaid and scale back subsidies for middle-income people to buy private insurance.

The plan, drafted with encouragement from Republican leaders in the Senate and the House, would retain some consumer protections in the Affordable Care Act, but would reduce federal regulation of insurance policies. States would have more authority to specify the ''essential health benefits'' that must be provided by insurance. As an example, the federal government would no longer require insurance policies to include coverage for maternity care.  

The proposal was devised by Senator Orrin G. Hatch of Utah, the chairman of the Finance Committee; Representative Fred Upton of Michigan, the chairman of the Energy and Commerce Committee; and Senator Richard M. Burr of North Carolina, a member of the Finance and Health committees.

In documents sketching their proposal, Republicans said their ''blueprint'' would lower costs and rebut criticism from Democrats who say the Republicans have no ideas on health care.

Republicans said the need for such an alternative had become more urgent because they now control both houses of Congress, and the Supreme Court could upend the president's health care law with a ruling later this year.

Their plan includes a potentially explosive proposal: Workers would have to pay federal income tax on the value of employer-provided health benefits that exceed certain annual thresholds -- $12,000 for individuals and $30,000 for families. Health benefits above those levels would be treated and taxed as regular income for the employee. The thresholds would increase over time.

Employers could still take tax deductions for the cost of employee health benefits as an incentive to continue providing coverage, Republicans said. Moreover, a summary of the proposal says that ''economists across the political spectrum largely agree'' that the current tax break for employer-provided insurance is fueling the growth of health costs.

Employees and employers have been vocal in their objections to proposals that would limit the tax break.

Sylvia Mathews Burwell, the secretary of health and human services, said Wednesday that almost 10 million people would have coverage this year through the public insurance marketplaces created under the Affordable Care Act. Nearly 7.5 million people have selected plans or were automatically re-enrolled through the federal exchange, she said, and 2.4 million people have been signed up through state-run exchanges.

Republicans said their plan did not include a federal exchange, but would allow states to run such marketplaces if they wanted to.

The Republicans did not provide a formal estimate of the cost of their proposal or the number of people who would be covered. Democrats have criticized such plans in the past, saying that they would not achieve the coverage gained under the Affordable Care Act.

The Republican plan would repeal the individual and employer mandates under which most Americans must carry insurance and larger employers must offer it to employees or else pay penalties.

''If consumers do not want to buy coverage, they don't have to,'' according to a document describing the Republican plan.

The Republicans would also repeal more than a dozen new taxes and fees, including taxes on insurance companies and manufacturers of prescription drugs and medical devices.

The government would offer subsidies, in the form of tax credits, for the purchase of ''health care coverage or services,'' according to the proposal. The subsidies would be available to people with incomes up to three times the poverty level (up to $35,300 for an individual), compared with four times the poverty level under the Affordable Care Act. 

Lower-income and older people would receive larger subsidies, but the average amount would be less than the current subsidies, which, according to the Congressional Budget Office, are now expected to total $1 trillion over 10 years.

Under the Republican proposal, the government would provide a ''capped allotment'' to states to finance coverage for certain Medicaid beneficiaries. Money would be allocated according to the number of poor people in each state. The amount would increase at the rate of the Consumer Price Index plus one percentage point and would ''reflect demographic and population changes.''

Republicans said Medicaid expansion under the current law was financially unsustainable.

The Republican proposal says that ''no one can be denied coverage based on a pre-existing condition,'' but this guarantee would apply mainly to people who had been continuously covered by insurance. For people who are uninsured, the Republican plan envisions ''a one-time open enrollment period in which individuals would be able to purchase coverage regardless of their health status or pre-existing conditions.''

Republicans would still allow young adults to stay on their parents' health care plan until age 26, but states could ''choose to opt out of this provision.''

The government would allow more variation in premiums based on the age of policyholders. Under current law, insurers generally cannot charge older Americans more than three times what they charge younger people, other factors being equal. Republicans would allow a ratio of five to one, with states permitted to set more or less restrictive rules.

URL: http://www.nytimes.com/2015/02/05/us/politics/gop-lawmakers-propose-alternative-to-obamacare.html

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November 6, 2014 Thursday  
Late Edition - Final

G.O.P Win Is Expected to Open Some Doors

BYLINE: By NELSON D. SCHWARTZ and CLIFFORD KRAUSS

SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1

LENGTH: 1249 words

After years of gridlock in Washington, American business is gearing up for a major push on long-sought goals like an overhaul of the corporate tax system, building the Keystone XL oil pipeline, lighter environmental and financial regulation and winning congressional backing for trade deals with Asia and Europe. Business interests face a much more receptive audience now that Republicans are poised to control both the House and Senate next year.

But despite plenty of public talk of more aggressive action -- like a rollback of the Affordable Care Act or the Dodd-Frank rules passed after the financial crisis -- lobbyists, experts on Wall Street and political veterans say the actual legislative agenda will be much more limited.

''There is a pent-up demand for legislative action, and there was a logjam because of the campaign,'' said Bill Miller, a veteran lobbyist and senior vice president at the Business Roundtable, which represents a wide cross-section of the biggest American companies. 

''The three issues we've got teed up now are corporate tax reform, then immigration reform, as well as getting new trade agreements passed.''

While many of the more conservative Republicans elected on Tuesday made their opposition to the Affordable Care Act a touchstone of their campaigns, there is much less appetite on the part of business leaders for wholesale changes to the health care law.

For one thing, many of the insurance exchanges are finally working well, and businesses have adapted to the new landscape. Even more important, added demand from the newly insured is likely to increase profits in sectors like hospitals, pharmaceuticals and medical devices.

''Anything regarding the Affordable Care Act is going to be a stretch,'' said John K. Lynch, regional chief investment officer for Wells Fargo Private Bank.

Similarly, insiders in Washington and on Wall Street say any effort to reverse the Dodd-Frank financial overhaul or completely defang the Consumer Financial Protection Bureau is unlikely to succeed.

Not that some opponents won't try. Senator Richard C. Shelby, an Alabama Republican who is slated to be the next chairman of the Senate Banking Committee, has called the bureau ''the most powerful yet unaccountable bureaucracy in the federal government.''

One possible compromise might be the creation of a five-member panel of commissioners to oversee the bureau, experts said, much like the ones that oversee the Securities and Exchange Commission and several other regulatory agencies.

''There will be a lot of hyperbole and table-pounding, but the outcome will be incremental, not overwhelming,'' said Steve Bartlett, a former Republican lawmaker from Texas who served as chief executive of the Financial Services Roundtable, an industry group, from 1999 to 2012. ''The C.F.P.B. isn't going away, and I've told companies that.''

Business leaders sounded an optimistic note in the wake of the election Wednesday, while also acknowledging that Washington may not change its ways.

''There's been dysfunction for the last several years in the leadership of both political parties and both branches of government,'' said Doug Oberhelman, chief executive of Caterpillar.

''People are fed up, and this should be a wonderful wake-up call for our leaders,'' he said. ''Both parties should hear it, and if they don't we're headed for a really big tidal wave in 2016.''

After pouring hundreds of millions of dollars into the most expensive midterm election in history, corporate donors are eager to see their agenda tackled by a party that has traditionally been much more sympathetic to big business.

''With the Republicans controlling both houses, the corporations that have been financing their campaigns for years are going to expect to see a return on their investment,'' said Robert J. Shapiro, who was a top Commerce Department official in the Clinton administration and is now chairman of Sonecon, a Washington economic and security consulting firm.

He foresees a big push to lower the corporate tax rate while closing some loopholes so that the package does not reduce overall revenue for the government.

American companies have also been pressing Washington for a deal that would let them bring back profits earned overseas without incurring the current 35 percent federal tax rate on corporate earnings.

Known as repatriation, advocates say it could bring back the roughly $2 trillion in earnings companies have stashed abroad for new investments or dividends in the United States. As with the rest of corporate tax reform, broad changes in tax law like this have proved elusive in the past, but President Obama has suggested a possible deal in which some of the revenue from that move would be used to help finance investments in infrastructure projects.

''There's a great desire for it, and the idea of tax reform is great, but the details are really tough,'' said Tony Fratto, who served in the White House and the Treasury Department under President George W. Bush, and is now a top communications consultant for companies like G.E. and several major financial services firms at Hamilton Place Strategies in Washington.

In addition, any tax break for business would be a tough sell at a time when many Americans remain frustrated with the economy and have not profited much from a booming stock market or surging corporate profits.

''The beneficiaries will be multinationals with business overseas,'' Mr. Fratto said. ''I believe it would help the economy but it's hard to explain politically.''

In theory, new trade deals with Europe and Asia have support from the White House and many Republicans, but rounding up the votes to pass them will also prove politically difficult.

An overhaul of immigration laws is an even tougher issue because there are deep divisions within the Republican Party on how to change the system, Mr. Shapiro said, with the conservative base at odds with the desire of business to make it easier for immigrants to establish legal status in the United States.

By contrast, there is more of a common denominator among Republicans on easing government supervision of business. ''Both the Tea Party types and the establishment wing of the Republican Party agree on wanting less regulation,'' Mr. Shapiro said.

The Republican takeover of the Senate is likely to sharpen debate on a number of energy issues, and, with support from several Democrats from energy-rich states, put pressure on President Obama to finally decide whether to allow the Keystone XL pipeline to be built to connect Canadian oil sand fields with American refineries on the coast of the Gulf of Mexico.

Republicans in Congress are also expected to try to curb plans by the administration to control greenhouse gas emissions by imposing strict new rules on coal-fired power plants.

Oil executives expressed exuberant satisfaction with the election results.

''The Republican-controlled Congress can start making the president make some decisions on energy matters -- from the Keystone XL pipeline to lifting the ban on crude exports,'' said James W. Noe, a senior vice president of Hercules Offshore, a drilling company that works in the shallow waters of the Gulf of Mexico.

The Republican Senate victory is also expected to elevate Senator Lisa Murkowski of Alaska to chairwoman of the Energy Committee. She has been a strong advocate for enabling liquefied natural gas exports, and she can also be expected to oppose any new rules aimed at limiting hydraulic fracturing in shale oil and gas fields.

URL: http://www.nytimes.com/2014/11/06/business/republican-election-victory-seen-as-positive-for-business-but-others-temper-expectations.html

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REGULATION: Richard Shelby, right, expected to head the Senate Banking Committee, is a critic of financial regulation.
TRADE: Proposed agreements will get a fresh look, among them a 12- nation Pacific partnership that includes Japan. (PHOTOGRAPHS BY TOM PENNINGTON/GETTY IMAGES
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December 10, 2014 Wednesday  
Late Edition - Final

Economist Says He's Sorry for 'Arrogance' on Health Law

BYLINE: By ROBERT PEAR

SECTION: Section A; Column 0; National Desk; Pg. 22

LENGTH: 793 words

WASHINGTON -- Jonathan Gruber, the health economist whose incendiary comments about ''the stupidity of the American voter'' have embarrassed the Obama administration, apologized on Tuesday for what he described as his ''glib, thoughtless and sometimes downright insulting comments.''

''I am not a political adviser nor a politician,'' said Dr. Gruber, a professor at the Massachusetts Institute of Technology who was a paid consultant to the Obama administration in 2009 to 2010. 

Dr. Gruber minimized his role, saying he had used an ''economic microsimulation model'' to help the administration and Democrats in Congress assess the impact of policies in the Affordable Care Act. He later defended the law in a number of speeches. In one, he said the law had been adopted, in part, because of the stupidity of voters and a ''lack of transparency'' about its financing.

Testifying on Tuesday before the House Committee on Oversight and Government Reform, Dr. Gruber said: ''I behaved badly, and I will have to live with that, but my own inexcusable arrogance is not a flaw in the Affordable Care Act. The A.C.A. is a milestone accomplishment for our nation that already has provided millions of Americans with health insurance.''

The chairman of the committee, Representative Darrell Issa, Republican of California, said backers of the law had passed it and sold it to the public with half-truths and deception. He added that Dr. Gruber and the administration had displayed ''a pattern of intentionally misleading the public about the true nature and impact of Obamacare.''

The senior Democrat on the committee, Representative Elijah E. Cummings of Maryland, joined in the criticism of Dr. Gruber. He said his comments were ''absolutely stupid'' and ''incredibly disrespectful.'' Worse, he said, the statements gave Republicans ''a political gift in their relentless campaign to tear down'' the law.

Mr. Issa showed a video in which Dr. Gruber suggests that supporters of the health law had written it in such a way that the Congressional Budget Office would not count required premium payments as tax revenue.

''This bill was written in a tortured way to make sure C.B.O. did not score the mandate as taxes,'' Dr. Gruber says in the October 2013 video. ''Lack of transparency is a huge political advantage. And basically, call it the 'stupidity of the American voter' or whatever, but basically that was really, really critical to getting the thing to pass.''

He appeared to squirm on Tuesday under questioning by Republicans who confronted him with his own past statements. He did not deny or recant those statements, but said he regretted some of his impolitic formulations. ''I made a series of statements that were really just inexcusable,'' Dr. Gruber said toward the end of the four-hour hearing.

''It is never appropriate to try to make oneself seem more important or smarter by demeaning others,'' he also said. ''I know better. I knew better. I am embarrassed, and I am sorry.''

Dr. Gruber infuriated Republicans on the committee by refusing to disclose the total amount of money he had received in grants and contracts from the federal government and states for work related to the Affordable Care Act. He also declined to say if he would provide copies of documents that he had prepared for federal and state agencies.

Representative Jason Chaffetz, Republican of Utah, told Dr. Gruber: ''You have been paid by the American taxpayers. Will you provide that information to this committee?''

Dr. Gruber replied repeatedly, ''You can take it up with my counsel.''

In an interview, Mr. Chaffetz said he would insist on the requests after he becomes the panel's chairman in January. ''Mr. Gruber will cough up those documents one way or another,'' he said.

Though he strongly supports the health law, Dr. Gruber has made statements that appear to undercut arguments now being pushed by the Obama administration in court cases challenging the payment of premium subsidies in states using the federal insurance exchange. Under the law, the federal government provides a backstop if states fail to establish exchanges.

''What's important to remember politically about this is if you're a state and you don't set up an exchange, that means your citizens don't get their tax credits,'' Dr. Gruber said in 2012.

By contrast, the White House has said that Congress intended for the subsidies to be available nationwide, in all states, regardless of whether they had a federal or state-run exchange.

Dr. Gruber said his earlier comments had been referring to the possibility that the federal government might not create a federal exchange.

''Your new explanation of your previous public statements makes little sense,'' Representative Justin Amash, Republican of Michigan, told him.

URL: http://www.nytimes.com/2014/12/10/us/jonathan-gruber-of-mit-regrets-arrogance-on-health-law.html

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(Ross Douthat)

November 7, 2013 Thursday

Different Kinds of Health Care Disruption

BYLINE: ROSS DOUTHAT

SECTION: OPINION

LENGTH: 1266 words

HIGHLIGHT: Comparing Obamacare’s disruption of existing insurance policies to the possible impact of conservative alternative.

After yesterday's detourinto electoral politics, let's turn back to the health care debate. Last week, amid the ongoing coverage of rising premiums and cancelled plans, the health care law's defenders took a new tack, arguing that the most plausible conservative alternatives to Obamacare would involve even more disruption of existing arrangements - with the implication being, then, that Republican outrage over "rate shock "is either straightforwardly cynical or else a sign that the G.O.P. would never, ever be willing to embrace a reform that disrupts the status quo at all.

This argument has some merit, for the reasons Philip Klein elaborated on here: You can't have health care reform without some kind of insurance disruption, and a Republican would-be reformer who made an Obama-esque "keep your plan" promise would either be exposed as a liar with similar alacrity or end up never actually undertaking reform at all. (This is yet another reason why a total death-spiraling exchange failure, coupled with a relative successful Medicaid rollout, would not necessarily leave conservative reformers in an ideal political spot.) 

But I also think it's useful to think about the differences between the kind of disruption that would accompany the most plausible conservative alternative to Obamacare and what we're actually witnessing today, because it helps clarify whether the Affordable Care Act actually represents what Jonathan Chait, speaking for the defense, calls "the least-disruptive, least-painful way" to expand insurance coverage.

The conservative alternative I have in mind is not what you might call "the full McCain" - the conversion of the existing employer tax exclusion for health insurance into a universal credit, which is an elegant idea in conception but which would indeed disrupt existing arrangements more dramatically than the Affordable Care Act, and which (on the evidence of the 2008 campaign) is about as politically sale-able as single payer. Rather, it's the more modest plan the American Enterprise Institute's James Capretta has done the most work fleshing out, in which a cap on the employer deduction helps pay for a flat credit available only to those Americans who don't receive coverage through their workplace.

Liberals object to this plan for a variety of reasons: The credit would fund catastrophic coverage rather than the comprehensive insurance they prefer, and it would require expanding high-risk pools to cover current uninsurables rather than folding them into the existing insurance system. But on the specific question of existing-plan disruption - who bears the burden of reform, and why - I think the Capretta plan has advantages over Obamacare that even liberals should be able to recognize.

That's because the way our system is set up right now, anyone who buys insurance on the individual market has been persistently disadvantaged, and often dramatically so, relative to anyone who gets insurance through their employer, because employer-provided insurance comes with an effective government subsidy ("worth more than $5,000 on a $13,000 employer-sponsored plan" for an upper middle class family, Capretta points out) while the individual marketplace does not. So a cap on the employer tax exclusion, while disruptive, would make the system fairer in clear, uncomplicated ways: It would curb a tax subsidy that mostly benefits people with higher incomes and only benefits people with expensive insurance plans, and extend that subsidy to people who have had to pay more, often much more, for insurance up until now.

By contrast, the Obamacare approach loads much more of the financial burden of reform on to the individual market, creating a stark, even chasm-like divide between that market's winners and losers and leaving the latter doubly-shafted: They still don't get a tax subsidy and their plans are getting a lot more expensive into the bargain.

Some of these losers are well-off, yes. But many of them are middle class, and not necessarily better off than the people who would lose out under an employer-exclusion cap. Moreover, there's a significant difference between what such a cap would actually do to people with employer-provided insurance and what Obamacare does to people with less-expensive individual market plans. The cap would basically give employers and employees a choice: Keep the expensive plans you currently have with higher premiums and co-pays attached (or with a higher tax bill at the end of the year), or shift down to plans with higher deductibles, network limitations, and so forth. This is not an easy choice by any means, and it would undoubtedly lead to the equivalent of some of the unhappy stories associated with Obamacare's regulations - people who feel like they can no longer afford coverage they like, people who end up losing access to their doctors and hospitals because their employer stops offering a plan, and so on. But I would submit that it's actually more humane to expose the already-subsidized to more of the real costs associated with their expensive insurance than it is to tell the persistently-unsubsidized that their most affordable insurance options are being outlawed, and that they are now required by law to pay more for more coverage (or, as often seems to be the case, to pay more for less).

What's more, as Reihan Salam points out in an exchange with Salon's Brian Beutler, this isn't an either-or choice, because Obamacare too includes a kludge-y version of the employer tax deduction cap in the form of the excise (or "Cadillac") tax on high-cost insurance plans: It's just set a higher threshold and thus applies to fewer policies than would the conservative alternative. That tax isn't scheduled to be implemented till 2018 (or year two of the Christie administration, if you prefer), so its effects aren't being fully felt as yet - but as the date gets closer, that provision will lead to rate increases and policy changes at the more expensive end of the employer market as well. So in comparing the potential disruptive effect of Capretta's cap-and-credit approach to the Affordable Care Act, you have to look at the complete picture: What we're seeing from Obamacare right now is only the beginning of the disruptions to existing plans, and today's individual market losers are only the first wave of people to whom the president's "keep your plan" promise doesn't actually apply.

The choice, then, isn't between gouging a few million people in the individual market or gouging a much larger number in the employer-based market. It's between a reform (the conservative alternative) that concentrates its disruptive impact the heretofore-oversubsidized portion of the marketplace, while trying to make the individual market more affordable for everyone who buys there, or a reform (Obamacare) that's disruptive for some people in the employer market but continues to protect most of them from the true price of their insurance, while pushing more of the off-budget cost of reform on to individual market premiums.

There are enough moving parts and unknown unknowns in each alternative that it's hard to say for sure which would one would ultimately be more disruptive in absolute terms (or even to define what those "absolute terms" would be). But I think there are various metrics - simplicity, equity, the choices left available and the incentives created - on which the conservative option might come out ahead.

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May 2, 2016 Monday 00:00 EST 

States Can Contain Health Care Costs. Here's How.;
Op-Ed Contributors

BYLINE: RICHARD M. SCHEFFLER and SHERRY GLIED

SECTION: OPINION

LENGTH: 994 words

HIGHLIGHT: Health care providers are consolidating. So are insurers. Regulation combined with competition can ensure consumers see the savings.

THE architects of the Affordable Care Act counted on competition in the health insurance market to keep costs down and quality high. While the law has accomplished many of its coverage and cost-containment goals, its vision of a more competitive insurance market seems to be fading.

The nation's second-largest health insurer, Anthem, is poised to acquire Cigna, the fourth-largest. Aetna, the third-largest insurer, is seeking to acquire Humana, the fifth-largest. If approved by the Justice Department, these mergers would produce companies controlling about 35 percent of the health insurance market. These mergers would likely leave that market with far fewer competitors - a disappointing result for those who hoped it would increase "choice and competition." Yet our research suggests that this apparent failure obscures a potential path to success, one that lies between competition and a fully regulated market. 

One reason behind the mergers is continued consolidation among hospitals and physician groups. From 2000 to 2013, the number of hospitals that were part of multisite health systems increased by 25 percent. More doctors are working for hospitals or for practices partly owned by hospitals; today, fewer than 20 percent of doctors are in solo practice. As provider organizations become larger, they gain more leverage in reimbursement-rate negotiations with insurers. To re-establish the bargaining balance between providers and insurers, insurers argue that they too must also get larger.

Our recently published research comparing New York and California, as well as previous analyses, suggest that there's truth to the insurers' argument. Consolidation in provider markets does raise health care prices. Insurer consolidation does reduce the prices paid to hospitals and physicians. Without further intervention, however, those price reductions don't get passed along to consumers.

The health care law offers an answer. Under the act, states have some flexibility in designing their marketplaces. States could, for instance, either accept all insurers who seek to participate or select a limited number to sell coverage. New York chose the first course, permitting all willing insurers to join; California chose the second, selecting 12 of the 32 insurers that initially showed interest.

This choice was critical because Covered California, the state's marketplace, used its leverage in selecting plans to keep initial premiums low. Before the marketplace opened, Covered California calculated how high premiums would need to be to cover the risks of covered populations and still generate a 2 percent profit for the insurers. California used these targets to select which insurers would be permitted to enter the market in the initial round. Then the state made a promise: Among those bidding for the first round, only those health plans selected would be permitted to offer plans for three years, except under unusual circumstances.

California also went further than New York in standardizing coverage. Under the Affordable Care Act, insurers in all marketplaces must offer a defined set of "essential health benefits" in all plans, and may offer plans at four coverage levels: platinum, the most comprehensive and expensive plans, followed in descending order of cost and coverage benefits by gold, silver and bronze. California went beyond this standardization by requiring that within each coverage level, all insurers offer the same deductibles and cost-sharing, and cover identical benefits. This made it easier for consumers to shop on price alone, rather than allowing insurers to obscure higher prices through complex and opaque benefit designs.

New York, by contrast, permitted insurers to offer not just standard plans, but also alternative plans with different cost-sharing and benefit designs.

When we examined the two states, we found that the effect of insurer competition differed greatly. In both states, areas with more hospitals had lower premiums compared with areas with fewer hospitals. But in New York, areas with fewer insurers had higher premiums, suggesting that insurers kept the benefits of greater bargaining power for themselves.

In California, by contrast, areas with fewer insurers also had lower premiums. Why? With initial premiums set at modest but adequate levels, and a vibrant marketplace, there was no need to further threaten insurers who might consider large premium increases. If an insurer tried to raise its premiums too far, consumers could easily shop among the restricted set of insurers for an identical product and switch to an alternative plan. Even in areas with fewer insurers, competition was sufficient to keep cost growth down.

The lesson here is that, especially in a health care system that is becoming more concentrated, competition and regulation can work together. A third party - governmental or quasi-governmental - can use its purchasing power to ensure that negotiating better health care prices benefits consumers, not just insurers.

Other states are getting into the act. Rhode Island has given its Department of Insurance authority to limit the price increases of inpatient and outpatient services; Massachusetts and Colorado have commissions that monitor costs and recommend action to the legislature to keep increases in health care under control.

Over time, we will learn more about how these alternative designs work. But one point is already clear: The choice between regulation and competition is a false one. To best manage our health care system, we will need both.

Follow The New York Times Opinion section on Facebook and Twitter, and sign up for theOpinion Today newsletter.

Richard M. Scheffler is a distinguished professor of health economics and public policy at the University of California, Berkeley. Sherry Glied is the dean and a professor of public service at the Robert F. Wagner Graduate School of Public Service at New York University.

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February 17, 2014 Monday  
Late Edition - Final

Writers Guild Plans Forum on Affordable Care Act

BYLINE: By MICHAEL CIEPLY

SECTION: Section B; Column 0; Business/Financial Desk; Pg. 6

LENGTH: 366 words

LOS ANGELES -- On Tuesday night, an expected crowd of 100 or so screenwriters and others will gather in Lower Manhattan at the headquarters of the Writers Guild of America East to hear thoughts about the Affordable Care Act and its place in comedy and drama. 

But whether any movie and television scripts that happen to be affected will have audiences laughing or crying about Obamacare still is not clear.

''This is such a contentious issue, no one's pretending'' there will not be robust disagreements on-screen, as in life, said Martin Kaplan, who spoke by telephone last week about the seminar, which drew criticism as a potential propaganda-fest in favor of the law when word of it surfaced last month.

Mr. Kaplan, as director of the University of Southern California's Norman Lear Center, helped organize the gathering under a grant made last fall by the California Endowment. That health-oriented nonprofit organization was financed by the insurance industry in a transaction that years ago turned WellPoint Health Networks into a publicly traded entity separate from the Blue Cross nonprofit group that had created it.

Early reports said the Lear Center and the endowment would work to promote enrollment in insurance plans under the new health law.

But after months of rancorous debate over the law and its troubled introduction, Mr. Kaplan and Michael Winship, president of the Writers Guild of America East, who spoke in a joint interview, were taking a more subdued approach.

''This is not about advising writers; we're in search of information,'' Mr. Winship said. He and Mr. Kaplan emphasized that conflicting views on Obamacare should be welcome in entertainment, as long as they are based in fact.

''Those writers can have any point of view they want,'' Mr. Kaplan said.

''If they think things went downhill when the 'public option' came off the table, that's O.K. too.''

Still, Tuesday's panel is not exactly packed with opponents of the law. It will be moderated by Mr. Kaplan and Mr. Winship, and includes Wendell Potter, a former insurance executive who has publicly defended Obamacare, and Julie Green Bataille, from the federal government's Centers for Medicare and Medicaid Services.

URL: http://www.nytimes.com/2014/02/17/business/media/writers-guild-plans-forum-on-affordable-care-act.html

LOAD-DATE: February 17, 2014

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March 19, 2012 Monday  
Late Edition - Final

Hurray For Health Reform

BYLINE: By PAUL KRUGMAN

SECTION: Section A; Column 0; Editorial Desk; OP-ED COLUMNIST; Pg. 21

LENGTH: 798 words

It's said that you can judge a man by the quality of his enemies. If the same principle applies to legislation, the Affordable Care Act -- which was signed into law two years ago, but for the most part has yet to take effect -- sits in a place of high honor.

Now, the act -- known to its foes as Obamacare, and to the cognoscenti as ObamaRomneycare -- isn't easy to love, since it's very much a compromise, dictated by the perceived political need to change existing coverage and challenge entrenched interests as little as possible. But the perfect is the enemy of the good; for all its imperfections, this reform would do an enormous amount of good. And one indicator of just how good it is comes from the apparent inability of its opponents to make an honest case against it. 

To understand the lies, you first have to understand the truth. How would ObamaRomneycare change American health care?

For most people the answer is, not at all. In particular, those receiving good health benefits from employers would keep them. The act is aimed, instead, at Americans who fall through the cracks, either going without coverage or relying on the miserably malfunctioning individual, ''non-group'' insurance market.

The fact is that individual health insurance, as currently constituted, just doesn't work. If insurers are left free to deny coverage at will -- as they are in, say, California -- they offer cheap policies to the young and healthy (and try to yank coverage if you get sick) but refuse to cover anyone likely to need expensive care. Yet simply requiring that insurers cover people with pre-existing conditions, as in New York, doesn't work either: premiums are sky-high because only the sick buy insurance.

The solution -- originally proposed, believe it or not, by analysts at the ultra-right-wing Heritage Foundation -- is a three-legged stool of regulation and subsidies. As in New York, insurers are required to cover everyone; in return, everyone is required to buy insurance, so that healthy as well as sick people are in the risk pool. Finally, subsidies make those mandated insurance purchases affordable for lower-income families.

Can such a system work? It's already working! Massachusetts enacted a very similar reform six years ago -- yes, while Mitt Romney was governor. Jonathan Gruber of the Massachusetts Institute of Technology, who played a key role in developing both the local and the national reforms (and has published an illustrated guide to reform) has surveyed the results -- and finds that Romneycare is working pretty much as advertised. The number of people without insurance has dropped sharply, the quality of care hasn't suffered, and the program's cost has been very close to initial projections.

Oh, and the budgetary cost per newly insured resident of Massachusetts was actually lower than the projected cost per American insured by the Affordable Care Act.

Given this evidence, what's a virulent opponent of reform to do? The answer is, make stuff up.

We all know how the act's proposal that Medicare evaluate medical procedures for effectiveness became, in the fevered imagination of the right, an evil plan to create death panels. And rest assured, this lie will be back in force once the general election campaign is in full swing.

For now, however, most of the disinformation involves claims about costs. Each new report from the Congressional Budget Office is touted as proof that the true cost of Obamacare is exploding, even when -- as was the case with the latest report -- the document says on its very first page that projected costs have actually fallen slightly. Nor are we talking about random pundits making these false claims. We are, instead, talking about people like the chairman of the House Republican Policy Committee, who issued a completely fraudulent press release after the latest budget office report.

Because the truth does not, sad to say, always prevail, there is a real chance that these lies will succeed in killing health reform before it really gets started. And that would be an immense tragedy for America, because this health reform is coming just in time.

As I said, the reform is mainly aimed at Americans who fall through the cracks in our current system -- an important goal in its own right. But what makes reform truly urgent is the fact that the cracks are rapidly getting wider, because fewer and fewer jobs come with health benefits; employment-based coverage actually declined even during the ''Bush boom'' of 2003 to 2007, and has plunged since.

What this means is that the Affordable Care Act is the only thing protecting us from an imminent surge in the number of Americans who can't afford essential care. So this reform had better survive -- because if it doesn't, many Americans who need health care won't.

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April 16, 2014 Wednesday

Stealth Taxes Are Still Income Taxes

BYLINE: CASEY B. MULLIGAN

SECTION: BUSINESS; economy

LENGTH: 785 words

HIGHLIGHT: The Affordable Care Act imposes economic burdens that are the equivalent of taxes, an economist writes.

Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."

For most Americans, the individual income tax returns they have filed over the last days and weeks are not much different than they were 10 years ago. But, in fact, taxes have changed dramatically over that period, behind the scenes and in support of health reform.

Western European governments have long provided medical assistance to all of their citizens, regardless of age or income. In contrast, the United States government has covered its poor, elderly and disabled and left the remaining majority of the population to privately finance its health care. 

It's not an accident that, by offering less coverage, America had lower health insurance payroll tax rates. The table below shows the rates for nine or ten other countries. (A number of countries are omitted because they do not have a specific payroll tax earmarked for their public health programs, although they do have public health programs and need a lot of taxes to pay for them. The countries also have different ways of collecting their payroll taxes, so my table translates their rates into an effective rate on employee paychecks that is economically comparable across countries).

Germany's government, for example, has a medical benefits payroll tax that is more than triple that in the United States. The average health insurance payroll tax rate in Western Europe has been more than twice as high as the rate in the United States. The contrast between the United States before the passage of the Affordable Care Act and Western Europe is consistent with the common sense idea that universal health coverage has a cost in the form of taxation of labor market activity. This is not to say that one system is better than the other. The point is that benefits appear to come with costs: more coverage requires higher tax rates.

If the United States government were to follow those in Western Europe and cover all of its citizens, one might guess that its payroll tax rates would have to be roughly four or five percentage points higher than they would be without universal coverage.

Yet the conventional wisdom is that the United States is now expanding coverage with hardly any new taxes on middle-class workers. In response to a request from Senator Tom Coburn, Republican of Oklahoma, the Joint Committee on Taxation named a few of the health care law's tax provisions as "directly affecting" individuals earning less than $200,000 annually and families earning less than $250,000, but they are relatively minor: On the order of $10 billion per year in an economy larger than $17 trillion.

As an official of the Department of Health and Human Services (it runs federal health programs) told The Washington Examiner, "The health care law will improve the affordability and accessibility of health care without significantly affecting the labor market."

Is it possible that, in writing the health care reform bill, America discovered a radical new way of financing public health coverage expansions without significantly burdening its labor market with taxes? Have the decades of high Western European payroll tax rates been unnecessary for governments to provide medical coverage for their nonelderly citizens? The answers are no.

The health overhaul contains a variety of hidden taxes - provisions that politicians and journalists do not call taxes, but nonetheless are the economic equivalent of taxes - that in combination have a lot in common with the payroll taxes that Europeans use to pay for their public medical programs.

For the most part, the new hidden taxes are economically equivalent to either employment taxes or income taxes. The hidden employment taxes require people with jobs to pay more to, or receive less from, the Treasury because they have a job. The foremost economic consequence of hidden employment taxes is less employment.

The law's hidden income taxes require people with high incomes to pay more to, or receive less from, the Treasury than people with low incomes do. Regardless of whether more taxes are collected from high-income families, more "means-tested" subsidies are paid to low-income families, or both, and the essential consequence is the same: less income.

In a forthcoming book and in commentaries, I will bring the new hidden taxes out into the open, quantify them and forecast their likely consequences for the labor market and the wider economy.

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April 27, 2017 Thursday  
Late Edition - Final

New Health Bill Has the Support Of Conservatives

BYLINE: By JENNIFER STEINHAUER and ROBERT PEAR; Thomas Kaplan contributed reporting.

SECTION: Section A; Column 0; National Desk; Pg. 1

LENGTH: 1405 words

WASHINGTON -- The House Freedom Caucus, a group of hard-line conservatives who were instrumental in blocking President Trump's plan to repeal the Affordable Care Act last month, gave its approval Wednesday to a new, more conservative version, breathing new life into Republican efforts to replace President Barack Obama's health law.

Senior White House officials, led by Reince Priebus, the chief of staff, have relentlessly pressed Republicans to revive the health care push before Mr. Trump's hundred-day mark on Saturday, and with conservatives falling into line, the bill has a chance to get through the House, possibly as early as Friday.

It was not clear whether conservative support for the revised legislation would be matched by losses in the center, especially among Republicans representing districts won by Hillary Clinton. But the rest of the House Republican Conference was left with a stark choice: Reject the measure and take the blame previously left at the feet of conservatives for undermining a central goal of the administration, or give it the nod, please voters who want a repeal, and risk taking a potentially fatal hit in the next election for approving a measure expected to leave tens of millions of Americans without insurance. 

''Members went home and got an earful,'' said Representative Tom Cole, Republican of Oklahoma, saying that voters were wondering, ''Why can't you get something done?'' Mr. Cole said he was now ''cautiously optimistic'' that the measure could pass on the floor.

The latest proposal, drafted by Representative Tom MacArthur, a moderate Republican of New Jersey, would allow states to obtain waivers from federal mandates that insurers cover certain ''essential health benefits,'' like emergency services, maternity care, and mental health and substance abuse services, which many Republicans argue have driven up premiums.

It would also permit states to get waivers allowing insurers to charge higher premiums based on a person's ''health status,'' if a state had a program to help pay the largest claims or had a high-risk pool where sick people could purchase health insurance.

To qualify for a waiver, a state would have to explain how it would advance at least one of five purposes: reducing average premiums for consumers; increasing the number of people with coverage; stabilizing the insurance market; increasing the choice of health plans; or stabilizing premiums for people with pre-existing conditions.

The House Freedom Caucus members, acutely aware that the White House and Republican colleagues blamed them for the failure of the earlier bill, were eager to shift the blame to more moderate members who may now reject the measure. And the biggest conservative pressure groups off Capitol Hill -- Heritage Action, Club for Growth and Freedom Partners -- dropped their opposition to the measure, known as the American Health Care Act.

''Over the past couple of months, House conservatives have worked tirelessly to improve the American Health Care Act to make it better for the American people,'' Alyssa Farah, a spokeswoman for the House Freedom Caucus, said in a prepared statement. Because of those changes, she added, ''the House Freedom Caucus has taken an official position in support of the current proposal.''

The group agrees to take an official position when 80 percent of its roughly three dozen members agree.

But what is good for the most conservative corners of the House is not necessarily going to please their colleagues, including the dozens who had already rejected a less-conservative version of the bill. Republican senators had been equally wary. ''I think a better approach is to stabilize the insurance pool,'' said Senator Bill Cassidy, Republican of Louisiana.

In effect, the more that the bill changes to get through the House, the less chance it has of surviving in the Senate, both because of Senate rules and because the provisions that conservatives have excised are popular.

A recent ABC News/Washington Post poll found that 62 percent of respondents supported nationwide minimum insurance coverage standards and just 33 percent would leave such standards up to the states. Among Republicans, 54 percent supported a nationwide standard for coverage of pre-existing conditions.

Republican senators from states that have expanded Medicaid under the Affordable Care Act said the new House bill did nothing to ease their concerns about the deep cuts to Medicaid that remain in the legislation.

''There's still going to be some of us here in the Senate who would like to weigh in, particularly on Medicaid expansion, which is not part of the bill,'' said Senator Rob Portman, Republican of Ohio.

Democrats assailed the latest proposal, saying it did nothing to help those who would be left without coverage under the repeal bill. By 2026, the number of uninsured people would be 24 million higher than under the current law, according to the nonpartisan Congressional Budget Office.

Democrats denounced one part of the new proposal that, they said, would protect health insurance for members of Congress. This provision, they said, guarantees that lawmakers would not lose ''essential health benefits'' and could not be charged higher premiums because of their health status. The group that helps elect House Democrats immediately unleashed internet ads in 30 Republican-held districts railing against the carve-out.

''The monstrous immorality of Trumpcare is perfectly encapsulated in House Republicans' plan to exempt their own health coverage from the damage it will do to everyone else,'' said the House Democratic leader, Nancy Pelosi of California.

Mr. MacArthur backed away from this part of his proposal on Wednesday. ''Congressman MacArthur does not believe members of Congress or their staff should receive special treatment and is working with House leadership to make absolutely clear that members of Congress and staff are subject to the same rules, provisions and protections as all other Americans,'' a spokeswoman said.

Mr. Trump, seeking a major legislative victory in his first 100 days in office, has been pressing hard to get a floor vote on a measure to repeal Mr. Obama's signature health care law and to fulfill a campaign promise of most Republicans for the better part of a decade.

Vice President Mike Pence and other White House staff have been feverishly trying to get the most conservative members to support a bill, even one that is not viable in the Senate, and without the input of many moderate members.

But the effort may be creating momentum.

''The key is, all of us recognize we and the president made campaign promises to repeal and replace Obamacare,'' said Representative Chris Collins, Republican of New York and a top Trump ally. ''We, as a team, all recognize we need to get to yes.'' He added, ''I am guardedly optimistic.''

Speaker Paul D. Ryan said Wednesday that a new bill could come to the floor at some point if sufficient support surfaced. ''We'll vote on it when we get the votes,'' he said.

As Republican leaders maneuvered toward a vote to repeal the Affordable Care Act, they were working to assure Democrats that the government would continue to subsidize out-of-pocket expenses for people buying insurance through the law's online marketplaces. Democrats have threatened to hold up legislation to keep the government funded past Friday unless they get guarantees that the so-called cost-sharing reductions would continue.

House Republicans had successfully sued the Obama administration to stop the payments, arguing that the administration was illegally spending money that Congress had not explicitly appropriated. By Wednesday afternoon, Democrats appeared convinced that the money would keep flowing, a significant promise that should help reassure insurance companies as they decide whether to offer policies on the marketplaces in 2018.

Ms. Pelosi neared a declaration of victory on that front, and on efforts to block funding this year for Mr. Trump's promised wall on the Mexican border.

''Our major concerns in these negotiations have been about funding for the wall and uncertainty about the CSR payments crucial to the stability of the marketplaces under the Affordable Care Act,'' she said. ''We've now made progress on both of these fronts.''

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URL: https://www.nytimes.com/2017/04/26/us/politics/affordable-care-act-health-republicans.html

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December 10, 2015 Thursday  
Late Edition - Final

Rubio Measure Delivers a Blow to Health Law

BYLINE: By ROBERT PEAR

SECTION: Section A; Column 0; National Desk; Pg. 1

LENGTH: 1355 words

WASHINGTON -- A little-noticed health care provision slipped into a giant spending law last year has tangled up the Obama administration, sent tremors through health insurance markets and rattled confidence in the durability of President Obama's signature health law.

The attack stems from two years of effort by Senator Marco Rubio and others in Congress to undermine a key financing mechanism in the law. So for all the Republican talk about dismantling the Affordable Care Act, one Republican presidential hopeful has actually done something toward achieving that goal.

Mr. Rubio's efforts against the so-called risk corridor provision of the health law have hardly risen to the forefront of the race for the Republican presidential nomination, but his plan limiting how much the government can spend to protect insurance companies against financial losses has shown the effectiveness of quiet legislative sabotage. 

The risk corridors were intended to help some insurance companies if they ended up with too many new sick people on their rolls and too little cash from premiums to cover their medical bills in the first three years under the health law. But because of Mr. Rubio's efforts, the administration says it will pay only 13 percent of what insurance companies were expecting to receive this year. The payments were supposed to help insurers cope with the risks they assumed when they decided to participate in the law's new insurance marketplaces.

Mr. Rubio's talking point is bumper-sticker ready. The payments, he says, are ''a taxpayer-funded bailout for insurance companies.'' But without them, insurers say, many consumers will face higher premiums and may have to scramble for other coverage. Already, some insurers have shut down over the unexpected shortfall.

''Risk corridors have become a political football,'' said Dawn H. Bonder, the president and chief executive of Health Republic of Oregon, an insurance co-op that announced in October it would close its doors after learning that it would receive only $995,000 of the $7.9 million it had expected from the government. ''We were stable, had a growing membership and could have been successful if we had received those payments. We relied on the payments in pricing our plans, but the government reneged on its promise. I am disgusted.''

Blue Cross and Blue Shield executives have warned the administration and Congress that eliminating the federal payments could have a devastating impact on insurance markets.

Twelve of the 23 nonprofit insurance cooperatives created under the law have failed, disrupting coverage for more than 700,000 people, and co-op executives like Ms. Bonder have angrily cited the sharp reduction in federal payments as a factor in their demise.

But Mr. Rubio is pressing forward, demanding a provision in the final spending bill now under negotiation that continues the current risk corridor restrictions, or even eliminates the program altogether. That enormous spending bill is being worked out as Congress slides toward a deadline of Friday, when much of the federal government's funding runs out.

''If you want to be involved in the exchanges and you lose money, the American taxpayer should not have to bail you out,'' Mr. Rubio said on the Senate floor on Thursday.

A White House spokeswoman, Katie Hill, declined to offer the administration's position on proposals that she said were still theoretical. ''We are not going to weigh in on the possible inclusion of proposals floated by members of Congress'' in potential legislation, she said.

Congress established the program in 2010 to protect insurers against the uncertainties they faced in setting the level of insurance premiums when they did not know who would sign up for coverage under the Affordable Care Act. Under the law, the federal government shares risk with insurers, limiting their gains and losses on insurance sold in the public marketplaces from 2014 through 2016. If consumer payments to an insurer exceed the company's medical expenses by a certain amount, the insurer pays some of that profit to the government. But if premium payments fall short of medical expenditures by a certain amount, the insurer is eligible for payments from the government.

The hope was that payments into the program would be in balance with payments out, shielding taxpayers from responsibility.

Mr. Rubio latched on to the issue in late 2013, recognizing not only the importance of risk corridors to the operation of the Affordable Care Act but also the political potency of a program he labeled crony capitalism -- putting taxpayers ''on the hook for Washington's mistakes,'' as he said when he reintroduced his risk corridor bill in January.

The ''bailouts'' of big banks and other financial firms during the economic crisis of 2008 and the rescue of the Big Three automakers that year and the next remain politically unpopular.

Then the numbers rolled in from the insurance exchanges' first year of operation: Losses were so steep that insurance-company requests for risk corridor payments were $2.9 billion, compared with only $362 million paid into the program by profitable plans.

Mr. Rubio says he ''saved taxpayers $2.5 billion'' -- the difference between those two amounts -- because his measure prevented the government from using other sources of money for the risk corridor payments.

The administration has repeatedly told insurers that it will explore other funding sources to keep its commitment to companies losing money in the exchanges, but Mr. Rubio effectively tied the hands of federal health officials this year.

Like many other observers of the health law, the Obama administration initially failed to appreciate the impact of the Rubio restrictions. Kevin J. Counihan, the chief executive of the federal insurance marketplace, told state officials in July that money collected from insurance companies would be ''sufficient to pay for all risk corridor payments.'' More recently, the administration consoled insurers by telling them that it would make additional risk corridor payments from money collected in 2015 and 2016.

But in a new report, the credit ratings agency Standard & Poor's says that money will not be there.

Mr. Rubio says Mr. Obama compounded his problems by diverting risk corridor funds to quell a 2013 furor over canceled insurance policies. That year, the president announced that states could let insurers renew canceled plans and continue coverage for several years even if those policies did not meet the requirements of the federal health law.

Insurers were shocked by the sudden change. They had set 2014 premiums on the assumption that healthy people with old insurance policies would move into the new marketplace, but Mr. Obama allowed many of them to stay out. In a letter to state insurance commissioners in November 2013, the administration said ''the risk corridor program should help ameliorate unanticipated changes in premium revenue.''

Five days later, Mr. Rubio introduced his bill to kill the risk corridor program.

Insurers now are lobbying to get more of the money they say they were promised, or to get relief in some other form.

Mr. Rubio has highlighted the role of Marilyn B. Tavenner, the former Obama administration official in charge of rolling out HealthCare.gov who is now president of the trade group America's Health Insurance Plans.

''The former Obama administration official who led the rollout of Obamacare's exchanges and now runs the health insurance lobby is working with her White House allies to secure a new bailout by providing more funding for the law's risk corridor program,'' Mr. Rubio said last week.

Clare Krusing, a spokeswoman for the insurance group, said the federal payments were not a bailout for the industry, but a way of stabilizing the market and thus protecting consumers. ''When health plans cannot rely on the government to meet its obligations,'' she said, ''individuals and families are harmed.''

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URL: http://www.nytimes.com/2015/12/10/us/politics/marco-rubio-obamacare-affordable-care-act.html

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January 5, 2017 Thursday  
The New York Times on the Web

The Parliamentary Tactic That Could Obliterate Obamacare

BYLINE: By ROBERT PEAR

SECTION: Section ; Column 0; SpecialSections; Pg.

LENGTH: 1169 words

WASHINGTON -- Republicans hope to repeal major parts of the Affordable Care Act using an expedited procedure known as budget reconciliation.

The process is sometimes called arcane, but it has been used often in the past 35 years to write some of the nation's most important laws. ''Reconciliation is probably the most potent budget enforcement tool available to Congress for a large portion of the budget,'' the Congressional Research Service, a nonpartisan arm of Congress, has said.

Here is a primer. 

Q. What is the budget reconciliation process?

A. It is a way for Congress to speed action on legislation that changes taxes or spending, especially spending for entitlement programs like Medicare and Medicaid. Although conceived primarily as a way to reduce federal budget deficits, it has also been used to cut taxes and to create programs that increase spending -- changes that can raise deficits.

In the Senate, a reconciliation bill can ordinarily be passed with a simple majority. For other bills, a 60-vote majority is often needed to limit debate and move to a final vote.

Q. Why is it called reconciliation?

A. The term originated in the Congressional Budget and Impoundment Control Act of 1974, which was intended to give Congress more control over the budget process by allowing lawmakers to set overall levels of spending and revenue.

The process begins with a budget blueprint, a resolution that guides Congress but is not presented to the president for a signature or veto. It recommends federal revenue, deficit, debt and spending levels in areas like defense, energy, education and health care.

The resolution may direct one or more committees to develop legislation to achieve specified budgetary results. By adopting these proposals, Congress can change existing laws so that actual revenue and spending are brought into line with -- reconciled with -- policies in the budget resolution.

Q. How has reconciliation been used?

A. Since 1980, Congress has completed action on 24 budget reconciliation bills. Twenty became law. Four were vetoed.

The Omnibus Budget Reconciliation Act of 1981 was a vehicle for much of the ''Reagan revolution.'' It squeezed savings out of Social Security, Medicare, Medicaid, food stamps, the school lunch program, farm subsidies, student loans, welfare and jobless benefits, among many other programs.

In 1996, Congress reversed six decades of social welfare policy, eliminating the individual entitlement to cash assistance for the nation's poorest children and giving each state a lump sum of federal money with vast discretion over its use. Those changes were made in a reconciliation bill, pushed by Republicans but signed by President Bill Clinton.

Congress reduced deficits with another reconciliation bill, the Balanced Budget Act of 1997. That law also created the Children's Health Insurance Program, primarily for uninsured children in low-income families. On the same day in 1997, Mr. Clinton signed a separate reconciliation bill that cut taxes.

The Bush tax cuts were adopted in reconciliation bills signed by President George W. Bush in 2001 and 2003.

On several occasions, Congress has increased assistance to low-income working families by increasing the earned-income tax credit in reconciliation bills.

Congress also made changes to the Affordable Care Act in a reconciliation bill passed immediately after President Obama signed the health care overhaul in 2010. Later, when Republicans controlled both houses of Congress, they passed a reconciliation bill to eviscerate the Affordable Care Act, but Mr. Obama vetoed the bill in January 2016.

Republicans say that measure will provide a template or starting point for their efforts to undo the health care law this year, with support from President-elect Donald J. Trump, who calls the law ''an absolute disaster.''

Q. How does the reconciliation process work in the Senate?

A. In the House, leaders of the majority party can usually control what happens if their members stick together. In the Senate, by contrast, one member or a handful of senators can often derail the leaders' plans. The reconciliation process enhances the power of the majority party and its leaders. Senate debate on a reconciliation bill is normally limited to 20 hours, so it cannot be filibustered on the Senate floor.

The Senate has a special rule to prevent abuse of the budget reconciliation process. The rule, named for former Senator Robert C. Byrd, Democrat of West Virginia, generally bars use of the procedure to consider legislation that has no effect on spending, taxes and deficits. The Senate parliamentarian normally decides whether particular provisions violate the Byrd rule, but the Senate can waive the rule with a 60-vote majority.

Q. What does this mean for the Affordable Care Act?

A. Republicans hope to use the fast-track procedure of budget reconciliation to repeal or nullify provisions of the law that affect spending and taxes. They could, for example, eliminate penalties imposed on people who go without insurance and on larger employers who do not offer coverage to employees.

They could use a reconciliation bill to eliminate tens of billions of dollars provided each year to states that have expanded eligibility for Medicaid. And they could use it to repeal subsidies for private health insurance coverage obtained through the public marketplaces known as exchanges.

Republicans could also repeal a number of taxes and fees imposed on certain high-income people and on health insurers and manufacturers of brand-name prescription drugs and medical devices: tax increases that help offset the cost of the insurance coverage expansions.

Those provisions were all rolled back in the reconciliation bill Mr. Obama vetoed last January. That bill did not touch insurance market standards established in the Affordable Care Act, which do not directly cost the government money or raise taxes. The standards stipulate, for example, that insurers cannot deny coverage or charge higher premiums because of a person's pre-existing conditions. Insurers must allow parents to keep children on their policies until the age of 26, and they cannot charge women higher rates than men, as they often did in the past.

Such provisions are politically popular, but it is not clear how they could remain in force without the coverage expansions that help insurers afford such regulations. Without an effective requirement for people to carry insurance, and without subsidies, supporters of the health law say many healthy people would go without coverage, knowing they could obtain it if they became ill and needed it.

Democrats say they will fight to preserve the law after Mr. Obama leaves office. Recent history shows that lobbying and public pressure can sometimes make a difference, altering the votes of individual lawmakers and changing the contents of a reconciliation bill.

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URL: http://www.nytimes.com/2017/01/04/us/politics/the-parliamentary-trick-that-could-obliterate-obamacare.html

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January 29, 2014 Wednesday  
The New York Times on the Web

Comparing Obamacare to Its Alternative

BYLINE: By EZEKIEL J. EMANUEL

SECTION: Section ; Column 0; National Desk; CONTRIBUTING OP-ED WRITER; Pg.

LENGTH: 1318 words

FROM the moment the ink dried on March 23, 2010, Republicans said they intended to ''repeal and replace'' the Affordable Care Act. They have voted more than 40 times to wipe the law from the books. But Republicans have never gotten around to describing, in detail, the set of policies they believe should replace Obamacare. That is, until yesterday.

After nearly four years, we finally have a Republican counterproposal: the Patient Choice, Affordability, Responsibility and Empowerment (or Patient CARE) Act.

Senators Tom Coburn, Richard Burr and Orrin Hatch deserve credit for developing this plan. Putting together a proposal to reform the American health care system is hard and politically courageous. And while it is lacking in important details, this plan contains some interesting ideas that might have enabled bipartisan compromises had they been offered in 2009, when I was a health care adviser to the Obama administration and the Affordable Care Act was being debated. For instance, the plan would shift many low-income adults from Medicaid to subsidized private insurance. There are some Democrats who could certainly have supported such a proposal, if it had been offered as part of a deal to enact a bipartisan bill. 

Despite all the heated rhetoric from Republicans about Obamacare laying ruin to America, the plan would actually keep some of the law's key provisions. It would preserve some subsidies for lower-income people to buy private insurance, though it would change the way they are calculated. Those $700 billion worth of Medicare savings Mitt Romney denounced during the 2012 campaign? Republicans would keep them. Allowing young adults to stay on their parents' plan until age 26? Republicans would keep that, too. And the ban on lifetime insurance caps, so people with very expensive diseases don't lose insurance? Republicans wouldn't touch it.

But in other crucial ways, the Republican plan is different. First, Obamacare's absolute ban on withholding coverage from people with pre-existing conditions would be rolled back. Those who remained continuously insured would stay protected, so they couldn't be charged higher rates or be excluded entirely. But if their insurance lapsed, health insurance companies could charge more or refuse to cover them.

Second, it would shrink the Medicaid expansion. Pregnant women, children and families below the poverty line would still be eligible, but childless adults would not. States would be given a fixed amount per person enrolled in Medicaid to reduce spending.

Third, the Republicans would provide tax credits for people to buy insurance, but only for families earning up to $70,650 per year. (The Affordable Care Act's subsidies go to families earning up to $94,200.) And employees of large companies, even if those companies did not offer health insurance, would be exempt, regardless of income.

The largest difference is in cost control. Currently, employer-sponsored health insurance is tax free; the Republican plan would make employees pay income tax on at least 35 percent of what their company pays for their plan. The idea is to make patients pay more for their coverage, giving them an incentive to choose cheaper health insurance plans with more deductibles and co-payments, which, in turn, would encourage them to shop around for cheaper tests and treatments and forgo unnecessary ones.

On a more individual level, this is what the Republican plan means: If you are one of the 150 million Americans who get their health insurance through an employer-sponsored plan, get ready for a big tax increase. For a family in the 28 percent tax bracket (earning around $150,000 per year), according to my calculations, it would add up to about $1,470 per year.

Here's how you get that number: In 2013, the average employer-sponsored insurance plan cost $16,351 for a family of four. On average, employers pay 72 percent of that premium, or $11,786. The Republican plan taxes 35 percent of the employer contribution, meaning that an additional $4,125 would be counted as income and subject to both payroll and income taxes. So that family would pay about $1,154 in income taxes and $316 in payroll taxes -- $1,470 per year. Obviously, people would pay even more if their health-insurance premium was higher, if they were in a higher tax bracket, or if their state had an income tax.

People who don't get insurance through their employer would also be likely to pay more. The Republican plan would provide the unemployed, people in the individual market and those working for small businesses that don't provide health insurance a tax credit to buy private insurance. But the credit increases only by age, not by need -- which means people with lower incomes would pay much more than they would under Obamacare. For example, under the Republican plan, a 30-year-old man living in New York City earning $35,000 a year would pay the full price of insurance, roughly $4,383 for a typical plan. Under Obamacare, he would pay $3,325. A 30-year-old earning $25,000 would get a $1,560 tax credit and pay roughly $2,823 under the Republican plan, but pay only $1,728 under Obamacare.

In addition, the proposed plan would take us back to the old days when insurance companies could charge women more than men for the same health plan. And older people would also be penalized. Under the Affordable Care Act, insurance companies are allowed to charge 64-year-olds only three times what they charge 21-year-olds. But the Republican plan allows insurance companies to charge 64-year-olds five times more. So a 64-year-old individual could pay as much as $21,900 for a plan that costs a 21-year-old only $4,380.

The plan would bring back many insurance company shenanigans. For instance, the decision to roll back the ban on excluding those with pre-existing conditions sounds O.K. in theory: ''individuals moving from one health plan to another -- regardless of whether it was in the individual, small group, or large employer markets -- could not be medically underwritten,'' meaning charged higher premiums based on a disease, and ''denied a plan based on a pre-existing condition if they were continuously enrolled in a health plan.'' So if you lose your job and therefore your employer-sponsored health insurance, you would not be excluded for a pre-existing condition if you immediately bought your own insurance. But if there were a gap in coverage, insurance companies could deny you coverage.

What if the paperwork you filled out is ''lost''? The history of insurance companies' tricks for denying coverage to high-cost patients -- like revoking the insurance of a cancer patient who failed to disclose that she had back problems -- does not inspire confidence.

Finally, there is the issue of prevention. The Affordable Care Act made preventive services free. To save money, Republicans want to reverse that, so that Americans will behave like cost-conscious consumers -- getting their blood tests at a cheaper laboratory or their CT scans at the cheaper imaging center. The problem is that mountains of evidence show that when patients have to pay, prevention is the first thing to go, in part because people aren't suffering pain or other symptoms, and the benefits of preventive services are typically years away. Saving money by cutting back these services makes no economic sense in the long-term.

There are many other problematic things the Republican plan does, like eliminate the health law's taxes on health insurance, drug and device companies; allow insurance companies to sell plans that don't cover maternity, mental health or other types of care; and allow insurance companies to impose annual limits on benefits.

We finally got the ''replace'' part of the Republicans' pledge to ''repeal and replace'' the Affordable Care Act. Now that Americans have the chance to examine the alternative, it might help them see the advantages of Obamacare.

URL: http://www.nytimes.com/2014/01/29/opinion/comparing-obamacare-to-its-alternative.html

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December 5, 2011 Monday

Labor Department Seeks Tougher Rules on 'Multiple-Employer' Plans

BYLINE: BRUCE JAPSEN

SECTION: HEALTH

LENGTH: 830 words

HIGHLIGHT: The federal agency says it wants more authority to crack down on insurance plans that take advantage of small businesses and their employees.

Federal officials hope to crack down more effectively on operators of "multiple employer" health plans that have defrauded small businesses and their workers of hundreds of millions of dollars, often leaving them stuck with unpaid medical bills, according to new rules proposed Monday by the Obama administration under the health care legislation.

Known as Multiple Employer Welfare Arrangements, or MEWAs, such plans have a checkered history under operators who used federal law in the past as a shield from state insurance investigators. The plans are set up for small businesses to provide their workers with lower cost coverage by pooling premium contributions from the employers and workers together for benefits that are paid from the arrangement.

Yet an unintended consequence of the Employee Retirement Income Security Act of 1974, which has restricted states from regulating multiple employer arrangements, allowed these plans to dodge state insurance examiners, often after high fees were paid and money was then unavailable to pay medical claims and other benefits.

In the last two decades, the Department of Labor said it had initiated 800 civil and more than 300 criminal investigations, but often had been unable to prevent the operators of the plans from draining assets of the plans through a variety of schemes that included "excessive administrative fees or outright embezzlement resulting in harm to participants and their families," the agency said in a statement.

Under the rules proposed Monday, the Secretary of Labor would have the authority to issue a "cease and desist order" when federal officials believe fraud is taking place. The secretary can also freeze assets, stop marketing and certain other business practices.

"For the first time, the federal government has some tools that we have never had to get at these MEWAS early before the money is gone and everybody is left in the lurch," said Phyllis C Borzi, assistant secretary of labor for the Employee Benefits Security Administration. "Once we have these new tools, hopefully the losses will go down because we will be able to intervene before the money is gone."

There have been many high profile cases of defrauded MEWAs, like that of TRG Health Plan, which had more than 11,000 plan subscribers and operated in more than 40 states and left behind more than $17 million in unpaid medical claims when it was terminated 10 years ago. The labor department alleged TRG's operators diverted assets to accounts of an affiliated marketing firm, failed to charge adequate premiums and did not have sufficient assets to pay benefits.

Often, small employers, unions or trade associations will turn to a MEWA for affordable benefits because an insurance company will not cover those who may have an older population of workers or employees who might be in poor health. So analysts say operators of MEWAs bilked the most vulnerable of Americans in search of affordable coverage for themselves and their workers.

Take the National Writers Union, which turned to a MEWA known as Employers Mutual when their insurance carrier dramatically raised rates. The plan, based in Nevada, sold benefits to 22,000 policy holders and was unlicensed in states, claiming its structure did not require it to be licensed. The plan left behind more than $24 million in unpaid claims, a 2004 General Accounting Office report said.

"Whenever people are desperate for affordable coverage, they look for alternatives and unscrupulous individuals target those kinds of people," said Mila Kofman, the former superintendent of insurance for Maine who is professor at Georgetown University's Health Policy Institute. "Many have been hauled into federal court but the U.S. Department of Labor didn't have tools to act quickly."

Federal officials estimate more than 2 million Americans are enrolled in hundreds of MEWAs but they cannot be certain because they don't know.

Another crucial part of the proposed regulations are that MEWAs have to register with the Department of Labor before operating or be subject to various penalties. The lack of licensure or registration made MEWAs a fertile opportunity for frauds.

"We don't even know how many of these there are," Ms. Borzi said.

Following a 90-day public comment period, the proposed rules will become final, probably by mid-2012.

The insurance industry, which is not known for welcoming new regulations, welcomed the labor department's proposals.

"We are pleased the government is going to have these added powers," said Alissa Fox, senior vice president of the Blue Cross and Blue Shield Association. "These entities are avoiding oversight and harming consumers. It hurts consumers and we are concerned when consumers are being hurt by entities that are not going to be paying these bills."

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December 8, 2016 Thursday 00:00 EST 

Harry Reid: Farewell, Fair Senate;
Opinion

BYLINE: HARRY REID

SECTION: OPINION

LENGTH: 879 words

HIGHLIGHT: Ending the ability to filibuster presidential nominations was the right thing to do, and I stand by it.

Washington - In my time in the Senate, I've served with 281 senators. I've rarely given advice unless asked. But since I am leaving the Senate floor for the final time, I have a few things to say.

To Republicans, I say recognize the difference between campaigning and governing, and beware of knee-jerk opposition to the accomplishments of the Obama era. 

Despite the fact that your nominee lost the popular vote by nearly three million votes, your leaders have announced their intention to repeal the Affordable Care Act early in the next Congress, with no replacement. This is a dramatic misreading of your mandate. It will lead you into a quagmire that will cause pain for millions of Americans and bedevil you for the next four years.

Repealing Obamacare will take health insurance away from millions of Americans - as many as 30 million, by one recent estimate. It will raise premiums and throw health insurance markets into disarray. Public support for repeal is low, and support for repeal without a replacement is in the basement.

If you continue down this path, you will be letting your reflexive opposition to President Obama's legacy cloud your judgment. I was in the Senate when President George W. Bush misread his mandate and sought to privatize Social Security. His administration never recovered.

To Democrats, I say it has never been more important to stand up for the things we believe in. We are entering a new Gilded Age. Next year, a billionaire president who just settled a fraud suit for $25 million over his business exploits will be pushing tax cuts for the top 1 percent, supposedly in the name of populism.

Much of the responsibility for separating what is real and what is fake will fall on Democrats. We should ask ourselves: Do the choices we make about how we spend our time keep us in touch with what we believe in, and what is real in our own lives?

For me, one of those choices has been to spend as much time as possible with the people who know me and know where I came from: a town called Searchlight. In the more than three decades I've been in Washington, there have by my count been 136 various press correspondents' dinners. I've been to one. And I might hold the record for spending as little time at fund-raisers as possible; I am usually in and out of the door in 10 minutes or less.

One thing we fought for that's worth defending is a fairer, more open and more productive Senate. We changed the Senate rules to guarantee a president's nominees a simple-majority vote, and declared that a president's nominees should not be stymied with procedural hurdles and a requirement for supermajority votes. (Supreme Court nominations still have this requirement.)

We declared that the changes should apply regardless of which party was in the White House, because fair votes are what democracy is all about. I doubt any of us envisioned Donald J. Trump's becoming the first president to take office under the new rules. But what was fair for President Obama is fair for President Trump.

Moreover, the rule change has been a victory for those who want to see a functioning, open and transparent Senate. It allowed Mr. Obama's judicial nominees to receive the just consideration they deserved. Without the rule change, Republicans would have been able to hold open three seats on our nation's second highest court, the District of Columbia Circuit Court, until the next Republican administration. The judges we confirmed to those seats will loom large in the years to come. In 2014 alone, the Senate confirmed 89 Circuit and District Court judges, more than for any year in two decades.

The rule change was consistent with the history of the Senate, which has continually evolved when faced with new challenges. Historically, the only way to reject nominees to cabinet posts, which are not lifetime appointments, has been by a simple-majority vote. Moreover, the supermajority threshold for bills and nominations is not in the Constitution, nor was it in the original Senate rules.

From George Washington to George W. Bush, only 68 presidential nominees had been filibustered. Senate Republicans took obstruction to a new level, filibustering 79 of Mr. Obama's nominees in just four years. By removing such procedural ploys, the rule change puts the debate over nominees out in the open. Senators have to answer a simple question: Should a nominee be confirmed, or not? Nominees are now guaranteed a floor vote.

With Republicans holding a slim majority, Democrats have a fighting chance at winning every debate. To be sure, persuading a majority of the Senate to your side is harder than blocking a confirmation on a procedural vote. But it is also fairer.

When Democrats pick their fights next year, they can do so knowing that, win or lose, they will be debating in a Senate that we made more open and more transparent. If Democrats stand for what they believe in, they will find that trusting the courage of their convictions while out of power will empower them to accomplish great things when the pendulum swings back, as it always does.

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Harry Reid is a Democratic senator from Nevada and the departing Senate minority leader.

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January 14, 2017 Saturday 00:00 EST 

The Optimism of Barack Obama;
Editorial

BYLINE: THE EDITORIAL BOARD

SECTION: OPINION; sunday

LENGTH: 936 words

HIGHLIGHT: Americans will miss both the character and eloquence of the president, who leaves a legacy of solid accomplishment despite bitter partisan opposition.

Barack Obama is leaving the White House with polls showing him to be one of the most popular presidents in recent decades. This makes sense. His achievements, not least pulling the nation back from the worst economic crisis since the Great Depression, have been remarkable - all the more so because they were bitterly opposed from the outset by Republicans who made it their top priority to ensure that his presidency would fail.

Many Americans celebrated the election of the first African-American president as a welcome milestone in the history of a nation conceived in slavery and afflicted by institutional racism. Yet the bigotry that president-elect Donald Trump capitalized on during his run for office confirmed a point that Mr. Obama himself made from the start: that simply electing a black president would not magically dispel the prejudices that have dogged the country since its inception. Even now, these stubborn biases and beliefs, amplified by a divisive and hostile campaign that appealed not to people's better instincts but their worst, have blinded many Americans to their own good fortune, fortune that flowed from policies set in motion by this president. 

That story begins on Inauguration Day in 2009. That's when Mr. Obama inherited a ravaged economy that was rapidly shedding jobs and forcing millions of people from their homes. The Obama stimulus, which staved off a 1930s-vintage economic collapse by pumping money into infrastructure, transportation and other areas, passed the House without a single Republican vote. Republican gospel holds that government spending does not create jobs or boost employment. The stimulus did both -preserving orcreating an average of 1.6 millions jobs a year for four years. (A timely federal investment in General Motors and Chrysler, both pushed to the brink during the recession, achieved similarly salutary results, preserving more than a million jobs.)

Mr. Obama's opponents have had trouble accepting that any of this actually happened. They have not learned the simple truth - a truth clear in the New Deal and just as clear now - that timely and significant federal investment can make a real difference in people's lives. Or accepted that compassionate and well-designed government programs can do the same. Driven by ideology or envy, or maybe both, Republican leaders have now pounced upon the demonstrably successful Affordable Care Act of 2010, a law that has improved the way medical care is delivered in the United States, providing affordable care for millions and driving the percentage of Americans without insurance to a record low9.1 percent in 2015. Despite the law's clear successes, Mr. Trump and Republican congressional leaders have nevertheless declared it a failure, hoping to justify a repeal that would roban estimated 22 million peopleof health insurance. The point of following this destructive course can only be to destroy a central Obama legacy - even though doing so will drive up costs and cause havoc in the lives of the newly uninsured.

With no help from Congress, Mr. Obama has also managed to make progress on issues where nobody gave him much of a chance, notably climate change, which both he and his secretary of state, John Kerry, placed very near the top of their to-do list. Against heavy odds, Mr. Obama first managed to persuade the Chinese to join the effort. This demolished the critics' argument that he was asking America to do all the heavy lifting. It also made possible the Paris agreement in December 2015, in which 195 nations agreed on a plan that they hope will reduce greenhouse gases that are warming the atmosphere and threatening the viability of the planet itself.

Americans will miss Mr. Obama's negotiating skills on tough issues and the dignity and character that he and his family brought to the White House. Beyond that, they will also miss an impassioned speaker whose eloquence ranks with that of Abraham Lincoln. The way he has defended the founding precepts of the United States while also arguing that those precepts have to be broadened to achieve a new inclusiveness has been especially striking, as have his remarks delivered at moments of national tragedy.

His 2015 eulogy in Charleston, S.C., after a Confederate flag-waving white supremacist slaughtered nine African-American parishioners at Emanuel African Methodist Episcopal Church, was redolent with history. As always, he viewed the horror through the prism of a seemingly innate optimism about the country's ability to set aside hatred and move toward a more perfect union.

Mr. Obama never would have gained the office without that unflagging optimism, which inspired a generation of young voters who saw in him a new kind of leader. So it seemed fitting that he would end his farewell address in Chicago on Tuesday with them in mind:

"Let me tell you, this generation coming up - unselfish, altruistic, creative, patriotic - I've seen you in every corner of the country. You believe in a fair and just and inclusive America; you know that constant change has been America's hallmark, that it's not something to fear but something to embrace; you are willing to carry this hard work of democracy forward. You'll soon outnumber any of us, and I believe as a result the future is in good hands."

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January 3, 2017 Tuesday 00:00 EST 

Trump and Senate Move Quickly to Repeal Affordable Care Act;
Transition Briefing

BYLINE: CHARLIE SAVAGE, MAGGIE HABERMAN and RICHARD PÉREZ-PEÑA

SECTION: US; politics

LENGTH: 2101 words

HIGHLIGHT: President-elect Donald J. Trump took to Twitter to denounce President Obama's signature domestic achievement, as Senate Republicans disclosed legislation to dismantle it.

" President-elect Donald J. Trump and Senate Republicans moved quickly to begin dismantling the Affordable Care Act.

" Hillary and Bill Clinton will attend Mr. Trump's swearing in on Jan. 20. Awkward.

" A White House job for Omarosa Manigault, the reality TV star.

Trump and Republicans take measures to gut the Affordable Care Act

That didn't take long.

Before the new members could even be sworn in, Senate Republicans revealed the parliamentary language that congressional Republicans will use to dismantle Mr. Obama's signature domestic achievement, the Affordable Care Act, without fear of a filibuster by Democrats in the coming months. 

The instructions are simple and vague: The Senate Finance and the Health Committees, along with the House Ways and Means and Energy and Commerce Committees, have until Jan. 27 to "report changes in laws" within their jurisdiction "to reduce the deficit by not less than $1,000,000,000 for the period of fiscal years 2017 through 2026."

Translation: The Senate and House have barely more than three weeks to complete legislation that reduces the deficit slightly over the next decade and, in the process, guts the Affordable Care Act beyond repair.

Debate will begin on the Senate floor on Wednesday, bypassing the Senate Budget Committee to speed passage.

Mr. Trump took to Twitter on Tuesday to amplify the message.

The rate increases, revealed in October, had long been predicted in Arizona, where many insurers had announced plans to drop out of the marketplace, and they affect a small fraction of residents. But they fit the Republican narrative that the law has made health care worse for Americans, despite the fact that it has provided coverage to tens of millions of previously uninsured people.

Left unsaid: What will happen to more than 20 million Americans now insured under the Affordable Care Act, or to the 27 percent of Americans with pre-existing medical conditions who, under the health care act, cannot be denied coverage by insurance companies?

The Clintons will attend Trump's swearing in

She called Mr. Trump "unfit" to be the commander-in-chief. He called her a "nasty woman." But Mrs.Clinton will be attending Mr. Trump's inauguration, along with her husband.

It is customary for former presidents and first ladies to observe the peaceful transfer of power in person. Former President George W. Bush and his wife, Laura, will also be in Washington on Jan. 20 for the inaugural festivities.

Not since Al Gore shared the stage with Mr. Bush in 2001 has such an awkward pairing occurred at an inauguration. Mr. Gore won the popular vote in 2000 and only conceded the loss after the United States Supreme Court intervened to stop a recount in Florida. Mrs. Clinton's loss was less contested, but her victory total in the popular vote, by 2,864,974 million votes, dwarfed Mr. Gore's 543,895 margin in 2000. Mrs. Clinton's total popular vote was the largest for a losing candidate since 1876.

A White House job for Omarosa

Omarosa Manigault, an original series star of Mr. Trump's reality television show "The Apprentice," is expected to have a senior role in the Office of Public Engagement at the White House, a senior transition official said.

Ms. Manigault has no government experience. But she has been deeply loyal to Mr. Trump, and was among his few well-known black supporters during the campaign.

Deval Patrick to Senate: Don't make Jeff Sessions attorney general

Deval Patrick, the former Massachusetts governor, made a forceful plea on Tuesday for the Senate not to confirm Senator Jeff Sessions of Alabama as attorney general, recalling when the two men were on opposite sides of a racially tinged case three decades ago, and calling Mr. Sessions "the wrong person to place in charge of our justice system."

In 1985, Mr. Sessions, then a federal prosecutor in Alabama, brought criminal charges against three black voting rights activists for helping older black voters, many of whom had been barred from voting for most of their lives, fill out absentee ballots. One of the lawyers for the defense in that case was Mr. Patrick, who was working for the NAACP Legal Defense and Educational Fund, and later became head of the Justice Department's civil rights division under President Bill Clinton.

A jury acquitted the defendants.

In a letter sent Tuesday to the Senate Judiciary Committee, Mr. Patrick, who is black, wrote that Mr. Sessions relied on a baseless theory - that helping someone to vote is illegal - and did so selectively, targeting black people who had helped black voters. Mr. Patrick is a Democrat, and Mr. Sessions, nominated by Mr. Trump to lead the Justice Department, is a Republican.

"To use prosecutorial discretion to attempt to criminalize voter assistance is wrong and should be disqualifying for any aspirant to the nation's highest law enforcement post," he wrote. And while absentee ballots were in widespread use, "Mr. Sessions investigated only the use by black voters and only where white incumbents were losing political ground."

Trump to Obama: No more releases from Guantánamo

It has been a busy day for the president-elect on Twitter, but he took the time to prepare his supporters for a late flurry of transfers from Guantánamo Bay that Mr. Obama plans in the coming days.

The New York Times reported last month that the Obama administration had deals to transfer about 18 of the remaining 59 detainees before Mr. Obama leaves office on Jan. 20. If all goes as planned, most would go to three gulf nations - Oman, Saudi Arabia and the United Arab Emirates - and be placed in custodial rehabilitation programs. One would go to Italy.

All of the men set to leave the prison are on a list of those recommended for transfer, if security conditions can be met in the receiving country, by six United States security agencies. Most have been held for about 14 years in wartime detention without trial and are from unstable countries, like Yemen, which complicated efforts to find a place to send them.

While Mr. Obama failed to fulfill his vow to close the Guantánamo prison, he refused to place any new detainees there and has whittled its population from the 242 prisoners he inherited from the administration of President George W. Bush.

Mr. Trump has vowed to keep the prison open and "load it up with some bad dudes."

Civil rights activists occupy Sessions's office

The protest season is beginning even before the swearing in.

Officials of the N.A.A.C.P. and its Alabama chapter occupied Mr. Sessions's office in Mobile, Ala., demanding that the senator withdraw his name from consideration to be the next attorney general.

Trump picks U.S. trade representative

Mr. Trump, whose campaign for the White House was centered on an anti-trade and anti-globalization message, on Tuesday selected Robert E. Lighthizer, an international trade lawyer who has argued in favor of protectionist policies in some cases, as his United States trade representative.

In Mr. Lighthizer, a top trade attorney representing multinational companies at Skadden, Arps, Slate, Meagher & Flom who was a trade official for Ronald Reagan, Mr. Trump has selected a seasoned negotiator who is intimately familiar with the benefits of global agreements. But Mr. Lighthizer has also been outspoken in pointing out their potential harm to United States interests. It is not clear what role he will play in the Trump administration now that the president-elect has created a White House National Trade Council and placed Peter Navarro, an economist who is a leading critic of China, at its helm.

Mr. Lighthizer has also been harshly critical of China, and in a 2010 Op-Ed article in The New York Times, he presaged some of Mr. Trump's talk on trade.

"Given the Tea Party's desire to restore America's greatness, it will push Washington to stand up to China and re-establish American pre-eminence, even at the cost of the country's free-trade record," Mr. Lighthizer wrote.

At the same time, he has lobbied on behalf of major American corporations to pry open foreign markets.

In response to the announcement, Senator Orrin G. Hatch, the chairman of the Senate Finance Committee and an ardent free-trade supporter, appears to have given up on the kinds of expansive multilateral trade deals, like the Trans-Pacific Partnership, that he once championed. What is left of the free-trade caucus now appears content with small deals with individual countries.

"The incoming Trump administration has a unique opportunity to pursue new, bilateral trade pacts of the highest caliber that can be submitted to Congress for an up-or-down vote with no amendments," Mr. Hatch wrote.

And speaking of trade ...

The president-elect, who targeted Boeing on its Air Force One upgrade, Lockheed on its advanced military fighter jet and, of course, Carrier on its Indianapolis furnace plant, seems to have taken a shine to General Motors.

In fact, it was President Obama who saved the Lordstown, Ohio, G.M. plant in 2009, with the auto bailout, visiting the factory that year to take a Chevrolet Cruze for a spin on the plant floor.

And G.M. has now responded:

G.M. imports hatchback versions of the Cruze from a factory in Ramos Arizpe, Mexico, which was only a small percentage of the 172,000 Cruzes sold through November, said Patrick Morrissey, a spokesman.

Obama's mission: Save the Affordable Care Act

With less than three weeks left before he leaves office, Mr. Obama has a more immediate concern in Congress: how to prevent Mr. Trump and Republicans from rolling back his domestic accomplishments, especially the Affordable Care Act.

Mr. Obama, who returned on Monday from a two-week vacation in Hawaii, plans to make a rare visit to Capitol Hill on Wednesday morning to huddle privately with House and Senate Democrats and discuss how to thwart the coming Republican assault on his legacy.

Democrats are strategizing about the best way to block the repeal of the health care law, as well as attempts to cut Medicare or Medicaid, and Mr. Obama has made it clear that he will use his remaining days in the White House to secure as many of his priorities as possible.

Mr. Pence will make a return to the Capitol - where he served for many years as a House member from Indiana - on Wednesday. He will be there to "discuss next steps to repeal and replace #Obamacare," Speaker Paul D. Ryan said on Monday on Twitter.

Bipartisan letter to Trump: Sell your businesses

A handful of Republicans - including several former governors and members of Congress - have joined with liberal ethics activists in pressing Mr. Trump to sell his business assets to prevent White House conflicts that could be "seriously damaging" to the presidency.

The letter sent to Mr. Trump includes the signatures of two former Republican governors, five former Republican members of the House and a collection of prominent ethicists, including Peter Schweizer, the editor at large of Breitbart and the author of "Clinton Cash," a book that criticized Hillary Clinton's connections to the Clinton Foundation.

In a number of cases, the Republicans who signed the letter have been critics of Mr. Trump since before the election, such as former Representatives Peter Smith of Vermont and Mickey Edwards of Oklahoma. Some Republican signers, such as Arne Carlson, a former governor of Minnesota, and Christine Todd Whitman, a former governor of New Jersey, supported Mrs. Clinton for president.

But the letter suggests that Mr. Trump is beginning to face calls from a broadening universe of people to take more aggressive steps to eliminate potential conflicts, such as selling off his real estate holdings and businesses before taking office.

"The only way to solve the problems you face remains divesting into a blind trust managed by an independent trustee or the equivalent," the letter says. "As long as you continue to maintain ownership of the Trump Organization, no other steps that you take will prevent the serious conflicts of interest."

The letter was organized by two former White House ethics lawyers - Richard W. Painter, who served under George W. Bush, and Norman Eisen, who served in the Obama administration - as well as Fred Wertheimer, the founder of an ethics in government group called Democracy 21.

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PHOTOS: Hillary Clinton with her husband, Bill, at President Obama's inauguration in 2013. (PHOTOGRAPH BY CHANG W. LEE/THE NEW YORK TIMES); Omarosa Manigault at Trump Tower on Monday. (PHOTOGRAPH BY HILARY SWIFT FOR THE NEW YORK TIMES)

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April 3, 2012 Tuesday

The President Fumbles the Court Issue

BYLINE: ANDREW ROSENTHAL

SECTION: OPINION

LENGTH: 626 words

HIGHLIGHT: President Obama needs to make a strong argument in defense of the Affordable Care Act if he wants to be re-elected. His remarks yesterday were a bad start.

I'm sure President Obama knows how important the Supreme Court's decision on health care will be to his re-election, not to mention the future of the country. And I'm equally sure he knows that the issue of Supreme Court appointments should figure highly in his campaign. If he loses, the nation faces what could be the most right-wing court in history, driven by a highly politicized agenda.

But Mr. Obama's maladroit handling of the issue yesterday left me wondering if he is going to be able to make that case effectively in the fall.

Mr. Obama was asked at a news conference about his health insurance reform law. He defended the constitutionality of the individual mandate that is at the core of the reform. He's right about that, and it's perfectly appropriate for him to defend the law.

But instead of offering a considered argument about the mandate's constitutionality and the court's jurisdiction in this case, he fumbled and stumbled into the ideological swamp usually occupied by Republicans when it comes to the court.

"I'd just remind conservative commentators that for years what we've heard is, the biggest problem on the bench was judicial activism or a lack of judicial restraint, that an unelected group of people would somehow overturn a duly constituted and passed law," he said. "Well this is a good example and I'm pretty confident that this court will recognize that and not take that step."

The reaction from the right was ridiculous. Conservative websites ran headlines saying that the president had made an outrageous attack on "unelected" judges. Senator Orrin Hatch, the Republican from Utah, called it a "fantasy" to think "every law you like is constitutional and every Supreme Court decision you don't is 'activist."

That is precisely the Republican yardstick for judging court decisions. The right consistently attacks the court with the argument that federal judges are unelected. Of course they are. That was exactly what the framers had in mind when they wrote the constitutional directive that federal judges be nominated by the president and confirmed by the Senate, shielding them from the whims and pressures of political campaigns. It's an especially important protection these days, when large moneyed interests are free to buy any election they want.

Judges, in the nation's system of separated powers, are assigned a distinct role, and it is not to be politicians in black robes. The protection of Americans' rights depends on having independent and fair-minded judges willing to strike down laws that trample on the Bill of Rights or otherwise overstep the constitutional powers of the executive branch-even when it may not be the popular thing to do. What courts should not do is second-guess legislative judgments that are well-within Congress's proper authority, based on ideological or policy differences. That is precisely the worry in the pending case of the Affordable Care Act. 

But Mr. Obama did not say that. He reduced the issue to a quick-and-easy sound bite and left himself open for the Republican attack with his ill-considered comments. In the case of the individual mandate, the issue is whether this court will sweep aside deeply established judicial precedent and cripple the government's ability to enforce the constitution's commerce clause. The mandate is clearly within that established legal framework. It's also troubling that some justices are more focused on whether they like this law than whether this law is constitutional.

That is the argument Mr. Obama needs to make. His comments yesterday were a bad start.

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The New York Times

October 15, 2016 Saturday  
Late Edition - Final

Beneficiaries Reflect Health Law's Strengths and Faults

BYLINE: By ABBY GOODNOUGH and REED ABELSON

SECTION: Section A; Column 0; National Desk; Pg. 10

LENGTH: 1466 words

WASHINGTON -- Cara Suzannah Latil is living proof that the Affordable Care Act works -- but also of why a central piece of the law is in turmoil.

Ms. Latil, 49, who works at a homeless shelter in Santa Fe, N.M., is one of millions of Americans who once found it difficult or impossible to get health insurance because they already had serious illnesses. Hepatitis C was ravaging her liver when she learned in 2014 that she also had breast cancer. Through the health care law, she was able to buy subsidized insurance that paid for all but $800 of her cancer surgery and radiation, she said, as well as tens of thousands of dollars' worth of medications that cured her hepatitis.

But stories like Ms. Latil's help explain a critical challenge for the health law: The subsidies it provides to help people pay for coverage, and the penalties for those who remain uninsured, have not coaxed enough young, healthy people into the insurance marketplaces it created. So the pool of customers in some parts of the country is too sick and too small.

Most Americans get their health insurance through their employers, or via Medicare or Medicaid. But millions who lack those options use the insurance markets set up under the law. 

It has turned out that so many marketplace customers need expensive medical care that some insurers are spending more on claims than they earn in premiums. And the federal government's strategies for protecting insurance companies from large losses have not been as effective as hoped.

Insurers, including a few big ones like Aetna and Humana, are withdrawing from the marketplaces in many states, saying they are losing too much money.

Others are sharply raising prices for next year, and the turbulence is fueling Republican criticism -- including from Donald J. Trump during Sunday's presidential debate, in which he called the rate increases ''astronomical.''

A few customers can generate big costs.

Even a small number of customers with serious conditions can greatly increase costs. Roy Vaughn, a senior vice president at BlueCross BlueShield of Tennessee, said that just 5 percent of the company's marketplace customers had accounted for nearly 75 percent of its claims costs.

The company recently announced that it would stop selling marketplace plans in Knoxville, Memphis and Nashville.

There are other reasons insurers are raising their rates or leaving the marketplaces. A big one is that the Obama administration, thwarted by Republican opponents in Congress, has paid out only a fraction of the $2.5 billion it owes insurers under a provision of the health law that was supposed to protect them against unexpectedly large losses during their first few years in the marketplaces.

But these payments would not be so important if more of the roughly 10 million marketplace customers were in good health. The Blue Cross Blue Shield Association reported in March that new customers who bought marketplace plans from its member insurers in 2014 and 2015 had higher rates of hypertension, diabetes, coronary artery disease, depression, H.I.V. and hepatitis C.

Chronically ill patients are worried about next year.

Many of these customers are in better shape after a few years with health insurance. But they are scared about the Affordable Care Act's future.

Marque Dailey of Dallas, who has multiple sclerosis, said his marketplace plan from BlueCross BlueShield of Texas had paid for visits to a neurologist, physical therapy and a drug called Lemtrada that is administered through two series of infusions a year apart. The list price for the treatment is $158,000, although insurers usually negotiate lower rates.

When Mr. Dailey, now 32, was uninsured, he could not treat his symptoms and had to rely more and more on a wheelchair. The stiffness in his legs got so bad, he said, that he had to quit his part-time job as a merchandiser at Coca-Cola, which did not offer insurance. Now he is working again, as a field organizer for a Democratic state legislative candidate. But Blue Cross narrowed the network of doctors and hospitals he could use this year, and he is worried that 2017 will bring even fewer choices.

''I understand I'm an insurance loss,'' Mr. Dailey said. ''I do feel bad about it. But without this, I'm just kind of left out of everything.''

Costs are burdensome to customers, too.

Other marketplace customers with expensive medical needs pointed out that the costs had been a burden to them as well as their insurers, most of which remain profitable even as they lose money in the Affordable Care Act markets.

Vickie Wilkerson, 46, of Shreveport, La., has a plan from Blue Cross and Blue Shield of Louisiana that she said had paid about $21,000 so far this year for injections of Stelara, a drug that has helped her severe psoriasis. She pays just $5 per shot, but only because by the time her doctor prescribed it this year, she had already met the $6,000 deductible on her plan. Two emergency room visits, for bronchitis and a bad fall, had left her with thousands of dollars in bills.

She chose a high-deductible plan, she said, because the subsidy she received covered the monthly premiums in full. She had not anticipated needing emergency care or being put on such an expensive drug. Nor had she realized that by choosing a different type of plan with higher premiums, she could have qualified for extra federal aid that would have helped pay her deductible.

Ms. Wilkerson, who never had insurance through her longtime job as a housekeeper, relied on sporadic charity care until getting marketplace coverage in 2014.

Her worst fear, she said, is that insurance companies ''will find some kind of loophole'' to deny coverage to people with existing conditions, as they did before the health law was passed.

''I don't know what I'd do,'' she said.

Her insurer is raising rates an average of 24 percent next year. But Ms. Wilkerson is looking into whether she qualifies for Medicaid now that Louisiana has expanded it under the Affordable Care Act.

''I'm finally on a medication that is working,'' she said. ''I don't want to have to stop that now and go back to the drawing board.''

Insurers are limiting choices.

Cathy Richardson of Elizabethtown, Pa., who works at her husband's small financial planning business, was a healthy, low-cost customer for the first two years she had coverage through the Affordable Care Act. But early this year, Ms. Richardson, 54, received a diagnosis of Stage 3 rectal cancer and quickly became expensive to her insurer, Capital BlueCross. She has had two operations, chemotherapy, radiation and two additional hospitalizations.

There are signs that Ms. Richardson's insurer is working to contain the costs of sick customers like her: It will not pay for treatment at the larger, more prestigious hospital in her area, requiring her to go to a smaller hospital instead. And a case manager from the insurance company calls her weekly to make sure she is getting the care she needs, which could prevent expensive complications.

The smaller hospital does not have a cancer center, so her oncologist, radiologist and surgeon do not work as a team. ''You have to navigate between the three of them,'' she said, ''and you never know who to go to.''

Still, her costs have been limited to about $5,200. She is bracing for a letter from her insurer, due this month, that will notify her of any price increase and changes to her coverage for 2017.

''Our choices are probably going to be pretty limited,'' she said.

Insurers are frustrated by customers dropping coverage.

The Obama administration is planning greater outreach, through advertising, social media, mailings and email, to new ways to persuade young, healthy Americans to buy marketplace coverage during the next enrollment period, which starts on Nov. 1. It is also taking other steps to address problems with the risk pool, which it says shows signs of improvement.

But insurers say they also wish the government could make it harder for people to drop their coverage after their health problem is treated. Health Care Service Corporation, which operates Blue Cross plans in five states, said less than half of its marketplace customers paid for coverage for the full year.

Ms. Latil dropped her coverage recently; she had finished her hepatitis treatment, a nearly six-month regimen of the drugs Sovaldi, Daklinza and ribavirin. It was not a willful swipe at the system, she said; she was struggling to make her premium payments of $179 a month.

''I got my stuff taken care of,'' said Ms. Latil, who will soon have insurance through her job. ''I am so extremely grateful.''

Follow Abby Goodnough @abbygoodnough and Reed Abelson @ReedAbelson on Twitter.

For more breaking news and in-depth reporting, follow @NYTNational.

URL: http://www.nytimes.com/2016/10/15/us/health-care-insurance-exchange-obamacare.html

LOAD-DATE: October 15, 2016

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GRAPHIC: PHOTOS: The stories of, from left, Marque Dailey, Vickie Wilkerson and Cara Suzannah Latil help explain the Affordable Care Act's critical flaws.(PHOTOGRAPHS BY COOPER NEILL FOR THE NEW YORK TIMES
MARK OVASKA FOR THE NEW YORK TIMES.) (A11)

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February 4, 2014 Tuesday

Times Minute | Army Recruitment Scam

SECTION: MULTIMEDIA

LENGTH: 66 words

HIGHLIGHT: Also on the Minute, a territorial dispute in the South China Sea and the effect of the Affordable Care Act on the full-time work force.

In the Video

 

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The New York Times

January 7, 2014 Tuesday  
Late Edition - Final

Another Modest Rise for Health Costs

BYLINE: By ROBERT PEAR

SECTION: Section A; Column 0; National Desk; Pg. 10

LENGTH: 834 words

WASHINGTON -- National health spending grew slowly for the fourth consecutive year, increasing 3.7 percent in 2012 to $2.8 trillion, the federal government said Monday. But officials disagreed over whether the Affordable Care Act or lingering effects of the recession were primarily responsible for the remarkable trend.

As a share of the economy, health spending declined slightly, to 17.2 percent in 2012, from 17.3 percent in the prior year. For decades, health spending has grown faster than the economy, taking a bigger bite out of workers' wages and the federal budget. 

Health spending averaged about $8,900 a person in 2012, according to the annual report issued Monday by the government.

The authors of the report -- civil servants at the Centers for Medicare and Medicaid Services -- said that the Affordable Care Act, adopted in March 2010, had only ''a minimal impact on overall national health spending growth through 2012'' and had not yet significantly reined in or accelerated its growth.

''The relatively low rates of growth that we've seen over the last four years are consistent with the historical trends that we've seen when we look at health spending and gross domestic product,'' said Aaron C. Catlin, an economist and co-author of the report. ''It's consistent with what we've seen in post-recessionary periods in the past.''

But the White House said the data vindicated President Obama's health care policies.

''The years 2009 to 2012 saw the slowest growth in U.S. health care expenditures since the government started collecting this information in the 1960s,'' said Jeanne M. Lambrew, a health policy coordinator at the White House.

''While there is a debate about how much the Affordable Care Act has contributed to this health cost slowdown,'' Ms. Lambrew said, ''there is no doubt that it reduced Medicare spending growth, and most experts believe that Medicare savings spill over into the private sector.''

Some experts, including the Congressional Budget Office, have reduced their projections of federal health spending, based in part on their belief that pervasive changes in the health care system would endure.

However, the authors of the new report, published in the journal Health Affairs, were more cautious.

''From our perspective,'' they wrote, ''more historical evidence is needed before concluding that we have observed a structural break in the historical relationship between the health sector and the overall economy.''

The last recession, the worst in decades, ran from December 2007 to June 2009. Mr. Catlin said that delayed effects of the recession -- curtailed growth of the economy, employment and personal income -- appeared to be the main reason for relatively low growth of health spending in recent years.

Some provisions of the new health care law increased spending and others reduced it, but the overall effects on spending were modest, said Anne B. Martin, an economist who was the principal author of the report. She estimated that the law had increased national health spending by a cumulative total of one-tenth of 1 percent from 2010 through 2012.

Comparing the experience of recent years, the report said that spending on hospitals and doctors increased at a faster rate in 2012 than 2011, while spending on prescription drugs and nursing homes grew more slowly.

Spending on hospital care increased 4.9 percent in 2012, to $882 billion, mainly because of a rise in prices and in the intensity and complexity of services, the report said. By contrast, the increase in 2011 was 3.5 percent.

At the same time, the report said, spending for doctors' services and outpatient clinics grew by 4.6 percent in 2012, to $565 billion -- up from growth of 4.1 percent in 2011.

But, it said, spending for prescription drugs grew just four-tenths of 1 percent in 2012, to $263 billion, compared with an increase of 2.5 percent in 2011.

''This reduced growth rate was driven largely by a slowdown in overall prices paid for retail prescription drugs as numerous brand-name blockbuster drugs -- most notably Lipitor, Plavix and Singulair -- lost patent protection in late 2011 and in 2012 and as generic versions became available,'' the report said.

Almost three-fourths of all prescriptions filled in 2012 cost $10 or less per prescription, the study said. Generic drugs accounted for 77 percent of all prescriptions filled in 2012, up from about 70 percent in 2011, it said.

The aging of the baby boom generation is reflected in the new data. Enrollment in Medicare increased 4 percent in 2012, the largest one-year increase in 39 years, the report said. More than half of the new beneficiaries joined Medicare Advantage plans managed by private insurers under contract with the government. More than one-fourth of the 50 million Medicare beneficiaries are now in such private plans.

Spending on Medicare increased 4.8 percent, to $573 billion in 2012, while federal and state spending on Medicaid, for low-income people, grew 3.3 percent, to $421 billion, the report said.

URL: http://www.nytimes.com/2014/01/07/health/health-spending-rises-slowly-for-fourth-year-in-a-row.html

LOAD-DATE: January 7, 2014

LANGUAGE: ENGLISH

GRAPHIC: CHART: Slow Growth in Health Spending: Experts at the Centers for Medicare and Medicaid Services said in a report that national spending on health care continued to be modest in 2012. (Sources: Centers for Medicare and Medicaid Services
National Bureau of Economic Research)

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The New York Times

October 21, 2015 Wednesday  
Late Edition - Final

Insurance Out of Reach for Many, Despite Law

BYLINE: By STACY COWLEY

SECTION: Section B; Column 0; Business/Financial Desk; Pg. 1

LENGTH: 1390 words

JACKSONVILLE, N.C. -- When Billy Sewell began offering health insurance this year to 600 service workers at the Golden Corral restaurants that he owns, he wondered nervously how many would buy it. Adding hundreds of employees to his plan would cost him more than $1 million -- a hit he wasn't sure his low-margin business could afford.

His actual costs, though, turned out to be far smaller than he had feared. So far, only two people have signed up.

''We offered, and they didn't take it,'' he said. 

Evidence is growing that his experience is not unusual. The Affordable Care Act's employer mandate, which requires employers with more than 50 full-time workers to offer most of their employees insurance or face financial penalties, was one of the law's most controversial provisions. Business owners and industry groups fiercely protested the change, and some companies cut workers' hours to reduce the number of employees who would be eligible.

But 10 months after the first phase of the mandate took effect, covering companies with 100 or more workers, many business owners say they are finding very few employees willing to buy the health insurance that they are now compelled to offer. The trend is especially pronounced among smaller and midsize businesses in fields filled with low-wage hourly workers, like restaurants, retailing and hospitality. (Companies with 50 to 99 workers are not required to comply with the mandate until next year.)

''Based on what we've seen in the marketplace, we're advising some of our clients to expect single-digit take rates,'' said Michael A. Bodack, an insurance broker in Harrison, N.Y. ''One to 2 percent isn't unusual.''

Nationwide, the Affordable Care Act has significantly reduced the number of Americans without health insurance. Around 10.7 percent of the country's under-65 population was uninsured in the first three months of this year, down from 17.5 percent five years earlier, according to the National Health Interview Survey, a long-running federal study. Some 14 million previously uninsured adults have gained coverage in the last two years, the Obama administration estimates.

Most of those gains, though, have come from a vast expansion of Medicaid and from the subsidies that help lower-income people buy insurance through federal and state exchanges. Workers who are offered affordable individual coverage through their employers -- a group that the employer mandate was intended to expand -- are not eligible for government-subsidized insurance through the exchanges, even if their income would otherwise have qualified them.

But for those trying to get by on near-minimum wages, a plan that qualifies as ''affordable'' can still seem far out of reach.

That is the case for many of Mr. Sewell's workers. He employs 1,800 people at the 26 Golden Corral franchises he owns in six Southern and Midwestern states, and previously offered insurance only to his salaried management staff. In January, when the employer mandate took effect, he made the same insurance plan, with a bigger employer contribution, available to all employees working an average of 30 or more hours a week.

Running the math on his plan -- a typical one for the restaurant industry -- illustrates why a number of low-wage workers are falling through gaps in the Affordable Care Act.

The annual premium for individual coverage through the Golden Corral Blue Cross Blue Shield plan is $4,800. Mr. Sewell pays 65 percent for service workers, leaving them with a monthly cost of $140.

The health care law defines affordable employer-sponsored insurance as that priced at 9.5 percent or less of an employee's annual household income for individual coverage. (Because employers do not know how much money their workers' relatives make, there are several ''safe harbors'' they can use for compliance, including basing their calculation on only their own employees' wages.) Mr. Sewell's insurance meets the test, but $65 per biweekly paycheck is more than most of his workers are willing -- or able -- to pay for insurance that still carries steep out-of-pocket costs, including a $2,500 deductible.

Clarissa Morris, 47, has been a server at the Golden Corral here for five years, earning $2.13 an hour plus tips. On a typical day, she leaves the restaurant with about $70 in tips. Her husband makes $9 an hour at Walmart but has been offered only a part-time schedule there, without benefits. Their combined paychecks barely cover their rent and daily essentials.

''It's either buy insurance or put food in the house,'' she said. On the rare occasions that she gets sick, she visits a local clinic with sliding-scale fees. It costs her $25 for a visit, and $4 to fill prescriptions at Walmart.

Brad Mete, the managing partner of Affinity Resources, a staffing agency in Dania Beach, Fla., began offering insurance this year to most of his workers only because the law required it. He said the alternative, paying a penalty of about $2,000 per full-time employee, was unthinkable, ''That would put us out of business, in one swoop.''

Trying to persuade his hourly workers to buy the insurance is ''like pulling teeth,'' he said. His company's plan costs $120 a month, but workers making about $300 a week are reluctant to spend $30 of it on insurance.

The employer mandate has not yet had any noticeable effect on the number of workers enrolled in employer-sponsored health plans, according to a survey by Mercer, a human resources consulting firm. Most of the newly eligible appear to be obtaining coverage elsewhere, such as through the plan of a parent or spouse, or are continuing to go without, said Tracy Watts, a Mercer consultant.

A study by ADP, the payroll processing giant, found an income tipping point at which most employees who are eligible for health insurance will buy it: $45,000 a year.

Workers making $15,000 to $20,000 a year buy employer-sponsored individual insurance when it is offered only 37 percent of the time. That rate rises at every income increment ADP studied until $45,000, when it reaches 82 percent and levels off. Further income gains have virtually no effect on the rate, ADP found.

The study was conducted in 2013, before many of the Affordable Care Act's provisions took effect, but ADP's recent figures do not indicate significant changes in that pattern, according to Christopher Ryan, an ADP research executive.

Low participation can pose problems for employers, especially smaller ones. Insurers are reluctant to sell policies to companies with low enrollment, because they fear that only the sickest employees will buy coverage.

Until this year, most insurers would not cover groups that fell short of their minimum participation requirements. The Affordable Care Act struck down that policy -- a sea change for the industry -- by prohibiting minimum participation rules from being used to deny coverage to any employer with 100 or more workers. But there is a big loophole: Insurers are required to issue the policies, but they are not required to renew them.

Mario K. Castillo, a lawyer in Houston who has extensively studied the new law, said it was poorly understood in the industry, and a bureaucratic nightmare.

''They have to issue you a policy, but dropping it after one year is perfectly legal,'' he said. ''If you're in this space, you essentially have to shop for insurance every year.''

For employees, forgoing coverage can mean facing tax penalties. Ms. Morris said she was surprised by the $95 fee she had to pay this year for being uninsured in 2014. ''I had kind of heard about it, but I didn't think it was going to kick in until later,'' she said.

Around 7.5 million taxpayers paid the fine, according to a preliminary report by the Internal Revenue Service. That is significantly more than the three million to six million the government had forecast.

Low-income, full-time workers like Ms. Morris may prove to be some of the hardest people to bring into the ranks of the insured, said Gary Claxton, a vice president at the Kaiser Family Foundation, which conducts an annual study on employer health benefits.

''This is one of the outcomes of trying to keep employer-based coverage in place,'' Mr. Claxton said. ''These are folks that didn't have coverage before, and they're not being given much help to get coverage now.''

URL: http://www.nytimes.com/2015/10/20/business/many-low-income-workers-say-no-to-health-insurance.html

LOAD-DATE: October 21, 2015

LANGUAGE: ENGLISH

GRAPHIC: PHOTOS: Billy Sewell said only two of his 600 workers at Golden Corral signed up for insurance. Clarissa Morris says she cannot afford it. (PHOTOGRAPHS BY LOGAN R. CYRUS FOR THE NEW YORK TIMES) (B7)

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The New York Times Blogs
(In Practice)

November 14, 2013 Thursday

California Shuts Down Sites Mimicking State Insurance Marketplace

BYLINE: Ian Lovett

SECTION: US

LENGTH: 393 words

HIGHLIGHT: The California attorney general’s office has shut down ten websites that mimicked state’s official health insurance marketplace.

LOS ANGELES-The California attorney general's office has shut down ten websites that mimicked state's official health insurance marketplace, the attorney general, Kamala Harris, announced Wednesday. 

"These websites fraudulently imitated Covered California in order to lure consumers away from plans that provide the benefits of the Affordable Care Act," Ms. Harris said in a prepared statement. "My office will continue to investigate and shut down these kinds of sites."

While not without its own hiccups, the rollout of the Affordable Care Act has been smoother in California than in many other parts of the country. Covered California, the state's insurance exchange, enrolled more people in private healthcare plans during the first month of open enrollment than any other state health exchange or the beleaguered federal marketplace, which serves 36 states.

Ms. Harris's announcement on Wednesday was the latest example of state officials in California, where Democrats hold all statewide offices, enthusiastically pushing Californians to buy healthcare plans on the state's exchange.

"I urge Californians to avoid healthcare scams by visitingcoveredca.com," Ms. Harris said.

The attorney general's office began investigating websites that imitated Covered California in September.

The sites all used domain names similar to coveredca.com, including coveredcalifornia.com and californiabenefitexchange.com, and they used phrases like "Get Covered" and "Covered California" to attract consumers, according to the attorney general's office. However, the sites were operated by private health insurance brokers not affiliated with the state's official exchange.

The California Affordable Care Act prohibits entities from claiming to provide services on behalf of Covered California without a valid agreement with the state exchange. Multiple website operators were sent cease and desist orders, demanding they either shut the sites down, or redirect traffic to the official Covered California website, and ten operators have now been shut down, according to the attorney general's office.

In urging residents to visit the state exchange, Ms. Harris warned that health insurance plans sold outside the official exchange before Jan. 1, 2014, would not qualify for federal subsidies, and would not have the consumer protections guaranteed under the Affordable Care Act.

LOAD-DATE: November 15, 2013

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The New York Times Blogs
(You're the Boss)

July 10, 2012 Tuesday

Having Lost the Health Care Battle, the N.F.I.B. Readies for a Long War

BYLINE: ROBB MANDELBAUM

SECTION: BUSINESS; smallbusiness

LENGTH: 1036 words

HIGHLIGHT: Acknowledging that full repeal is a long shot, the group seems to have settled on a less ambitious course of stripping the law of the elements it considers most odious.

Now that the Supreme Court has largely upheld the Affordable Care Act, what is the next move for the lead plaintiff in the suit to repeal the law? This, of course, is the National Federation of Independent Business, the small-business trade association, and while the N.F.I.B. might have found much to like in the Affordable Care Act - the whole notion of insurance exchanges where small companies could compare and then buy insurance coverage for their employees was taken directly from a bill that the federation helped write - it in fact found much more to dislike. Nothing is likely to happen before the election this November, said the federation's chief executive, Dan Danner, but the group is already preparing its Plan B - and Plan C.

The group's preferred outcome, full repeal of the health care law, does not require a change in election strategy, because the federation was likely to be supporting Republicans hostile to the health law anyway. But Mr. Danner acknowledged that full repeal was a long shot, and he seemed to have settled on a less ambitious course of stripping the law of what the N.F.I.B views as its most odious elements. "I think there's growing sensitivity on both sides of the aisle to some of the things in the legislation that without total repeal could be changed," Mr. Danner said.

To that end, he said, the group planned to spend the next four months pressuring candidates for Congress - Democrats and Republicans alike. For example, referring to the individual mandate, Mr. Danner rehearsed a question the group planned to pose to a Democratic senator in a very tight race for re-election: "Claire McCaskill, you're running for the Senate in Missouri, now that it's clear that we're talking about a tax, are you O.K. with that, this enormous new tax on largely the middle class and young people?" Mr. Danner said his group planned to question "pretty much everybody that's running." (Ms. McCaskill's office did not respond to a request for an answer to the N.F.I.B.'s question.)

Mr. Danner said the mandate would affect the federation's self-employed members - about 16 percent of the group's membership, according to Kevin Kuhlman, a manager for legislative affairs at the federation. Mr. Kuhlman added that the mandate would force other small business owners who could not afford insurance to buy it. "It diverts potential investment in a business to a product," he said. However, the nonpartisan Congressional Budget Office and Congress's Joint Committee on Taxation have estimated that in 2016 only four million people will have to pay the government for refusing to buy insurance, and many of these people would be upper-income.

Apart from seeing the individual mandate removed, the organization would like to repeal an annual fee on health insurers that Senate Democrats drafted to help pay for the overhaul. The provision, which the N.F.I.B. describes as a tax, will raise at least $87.4 billion from 2014 to 2020. "The tax will primarily be on health care plans in the small group market, where our guys are," he said, "so we're pretty confident that that $87 billion gets passed directly down to the small businesses purchasing health care." The Congressional Budget Office has also said that insurers will pass the cost of the fee to customers in premiums. Large companies typically self-insure, and self-insurance is excluded from the fee. (On the other hand, Jason Furman, an economic adviser to the Obama administration, points out that the C.B.O. has also predicted that exchanges paid for in part by the fee should actually make health insurance cheaper for small businesses by reducing administrative costs and increasing competition among insurers.)

And the group plans to push other changes. "We'd still like to see expanded, not diminished, use of health savings accounts and flexible spending accounts, because they're largely taken off the table in the law," Mr. Danner said. And "something that hasn't been addressed in the law, and we'd like to sure see added, because it goes directly to costs, is medical malpractice reform."

At the same time, employees at the Health and Human Services Department who are defining the health care law's essential benefits packages will continue to hear from federation lobbyists. The law requires the Health and Human Services Department to stipulate the minimum benefits for all plans in the individual and small group markets, and Mr. Danner said the federation is worried about additional coverage requirements that could drive up costs for employers. "It makes a great deal of difference if that's all the bells and whistles," said Mr. Danner. "The companies don't get to decide, unfortunately, what they provide. H.H.S. will decide that."

And the federation will be active in every state capital, too, because state governments are charged with setting up the law's insurance exchanges, one for individuals and one for small businesses. "Clearly in a lot of the states, things were somewhat on hold pending this decision, and now things probably move more quickly," Mr. Danner said. "We have a great deal of concern about how the exchanges are going to be set up, and if in fact they're going to offer lots of choices and lower costs for small business."

However, several Republican governors have said that they would at least wait until after the election to make a decision on whether to set up exchanges - where states do not create an exchange, the federal government was slated to do it for them - Mr. Kuhlman said later that the organization was not taking a stand on when, or whether, a state should begin work on its exchanges.

Mr. Danner said his organization hadn't t figured out what precisely it wanted in the exchanges. "We don't have a blueprint of how you should set up every state exchange," he continued. "But I think what we do want is a seat at the table as these are being set up in all the states, and we'll push pretty hard to have that."

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November 2, 2016 Wednesday  
Late Edition - Final

How Health Care Hurts Your Paycheck

BYLINE: By REGINA E. HERZLINGER, BARAK D. RICHMAN and RICHARD J. BOXER.

Regina E. Herzlinger is a professor of business administration at Harvard University. Barak D. Richman is a professor of law and business administration at Duke University. Richard J. Boxer is a professor at the David Geffen School of Medicine at U.C.L.A.

SECTION: Section A; Column 0; Editorial Desk; OP-ED CONTRIBUTORS; Pg. 25

LENGTH: 921 words

If there is a coherent theme to this year's election, it is the growing economic frustration of working Americans. While trade has been the chief scapegoat, a major culprit has received much less attention: the rising cost of health insurance.

Recent news of large price increases for plans on the Affordable Care Act's insurance exchanges was the latest example of an unsustainable trend. But those exchanges sell insurance to only about 12 million individuals. Most people with private health insurance, about 150 million individuals, receive coverage through employers. And for those people, prices have been rising for years.  

A Kaiser Foundation report released in September explained that since 1999, health care premiums for employer-sponsored insurance programs have risen more than three times faster than wages. Today's workers are paying an average of $18,000 for health insurance that covers fewer services each year, as employers shift costs to their employees through higher deductibles, co-payments and shares of premiums.

Unlike the plans purchased on insurance exchanges, where individuals pay directly for their policies, employers pay for most private health insurance on their employees' behalf. Economics research suggests that for each dollar an employer spends on an employee's health insurance premium, roughly one dollar is removed from that person's take-home pay. But these costs remain hidden. Workers know their take-home pay has stagnated, but they may not attribute that stagnation to health care costs.

Workers have little control over this enormous expense made on their behalf. Most have few, if any, health insurance options and cannot trade dollars spent on insurance for higher take-home pay. They cannot shop around for or economize on what is probably their most expensive annual purchase. In turn, insurers are not pressured to offer more affordable insurance products.

A minor tweak to our tax code could go a long way to bring more choice, affordability and personal control to how workers purchase health insurance. Current law allows individuals to avoid taxes on money spent on insurance premiums only if their employers purchase insurance on their behalf. What if employers transferred to their employees the amount they now spend on coverage and the law allowed employees to deduct that spending from their taxes?

And what if those laws allowed employees to opt not to spend that entire sum on health insurance, but instead take some home as wages? If an employee in a marginal tax bracket of 25 percent were given an $18,000 budget to purchase insurance, but opted for a plan that costs only $14,000, she could take an additional $3,000, post-tax, home to her family.

This slight change would turn the economic tables for the millions of Americans who get health insurance through their employers. Abundant research has shown that low- and middle-income workers have a strong preference for low-cost plans, much more than what their employers currently offer. If workers know they can increase take-home wages by purchasing less expensive insurance, they will demand more insurance options, and insurers are likely to respond. To avoid the chance that cash-strapped families purchase inadequate plans, insurance plans would have to meet the Affordable Care Act's minimum standards. The law's requirement to purchase insurance, with penalties for non-purchase, would lessen the possibility that workers would keep all the money rather than buy insurance.

Freeing workers' choices for insurance would also bring pressures on insurers to create new products that control costs, such as bundling of homeowners, auto and health insurances, or enabling people between 55 and 64 years old to access Medicare. State legislatures would feel similar pressures to adjust regulations to support competitive insurance marketplaces.

Stiffer competition and cost pressures on insurers, in turn, would force providers to offer more efficient care, such as by replacing outpatient and emergency room visits with telemedicine technology.

Our proposal charts a bipartisan path, bolstering the Democratic mandate for universal care working within the Affordable Care Act, while heeding the Republican call for competition and choice. It also presses further than the main presidential candidates. Hillary Clinton proposes reducing the cost of pharmaceuticals, eliminating taxes on high-end policies, improving cost transparency and allowing people over 55 to buy into Medicare. Donald J. Trump, who wants to repeal the Affordable Care Act, calls for creating tax-free health savings accounts and facilitating cross-state competition. Both recommend assorted tax credits. Each of these approaches aims to soften the effects of rising prices. But neither empowers workers to invigorate the marketplace and make prices more competitive.

America has prospered because it has harnessed the power of competitive markets to enable growth, and it is not hyperbole to say that middle-class disaffection threatens the very compact that generated this prosperity. Competitive markets do not merely force companies to act efficiently and produce valuable offerings. In assuring Americans that they can control their budgets and have a voice in their life decisions, they also serve as a reliable counterforce to the economic discontent that has roiled this election season.

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URL: http://www.nytimes.com/2016/11/02/opinion/how-health-care-hurts-your-paycheck.html

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(You're the Boss)

July 17, 2014 Thursday

Are More Companies Offering Health Insurance? For an Answer, Look to Massachusetts

BYLINE: ROBB MANDELBAUM

SECTION: BUSINESS; smallbusiness

LENGTH: 927 words

HIGHLIGHT: After the Massachusetts health insurance overhaul, there was an increase in the percentage of businesses offering their employees coverage.

For years, The Agenda has reported dueling predictions from economists and other pundits about whether businesses, especially small businesses, will stop offering health insurance rather than comply with the requirements of the Affordable Care Act. For an example, see Ezekiel J. Emanuel's claim that by 2020, more than 80 percent of private-sector workers will buy their own insurance.

The early evidence, however, suggests the opposite trend. An April study by the non-profit Rand Corporation found that in the six months between September 2013 and March 2014, the number of people who received health insurance through an employer grew from 109 million to nearly 117 million, an increase of about 8 percent. (The number of people who got new insurance from an employer was actually larger than that, but it was offset by the people who lost their company insurance, many of whom replaced that insurance with an individual policy or Medicaid.) 

A second, so far unpublished, study by the Urban Institute found a similar but smaller result - the growth in employer provided coverage was about half what Rand reported, according to Genevieve M. Kenney, a health economist with the Institute.

These studies, which rely on much smaller sample sizes than more authoritative government surveys, leave several questions unanswered. Chief among them is whether the increase reflects more workers accepting existing offers of insurance or more companies choosing to offer insurance. Nor is it clear whether the increase is occurring at small businesses, big businesses or both.

According to the latest data from the Census Bureau, businesses with 500 or more workers employ 51 percent of the workforce, while those with fewer than 500 workers have 49 percent. (Those with fewer than 100 workers employ 35 percent.)

To gauge what might be happening now, we can turn to the experience in Massachusetts, where a 2006 health care overhaul served as the model for the Affordable Care Act. And the Massachusetts experience is striking. There, too, in the first year after the overhaul took effect, the number of people insured through an employer grew - not by as much as the RAND and Urban Institute data project, but Massachusetts employers already covered a higher share of the state's residents than employers across America do today.

In the Bay State, the increase did not come from more workers deciding to accept existing offers of health insurance. According to data collected by the state, the so-called take-up rate in 2007 was the same as in 2005, 78 percent. What did change was the number of companies offering insurance. In 2005, 60 percent of the smallest companies - those with between two and nine employees - offered insurance; in 2007, that share shot up to 67 percent, a 12 percent increase. Interestingly, the effect was delayed among companies with between 10 and 50 employees. In 2007, the offer rate among those companies had not changed much from 2005. By 2009, though, the rate had increased to 92 percent from 88 percent before falling again in 2010. Across all Massachusetts businesses, most of which are small, the share offering health insurance increased about 10 percent from 2005 to 2010.

In a 2011 paper recapping the effects of the Massachusetts overhaul on insurance coverage there, Jonathan Gruber, a health economist who helped design the Affordable Care Act, argued that the pressure the individual mandate placed on people to have insurance forced more employers to offer it. "There is no obvious explanation for this increase in employer offering as the law introduces incentives for employers to drop insurance (by covering their low income employees outside the employer setting) and does little to penalize those firms that do drop coverage," he wrote. "The best potential explanation for this result is that there was a non-market impact of the mandate on employer behavior, with employees demanding coverage to meet the mandate and employers increasing coverage to meet the demand."

What was happening in the rest of the United States at that time? In the early 2000s, Massachusetts companies offered health insurance at a rate similar to the country as a whole. (The national rates for offering insurance have been reported over the years in the Kaiser Family Foundation's annual Employer Health Benefits Survey.) This was in large part driven by the smallest companies, which make up the largest share of all businesses. In those years, the share of very small Massachusetts companies that offered insurance closely tracked the national share, while the state's bigger small businesses (especially those with 10 to 24 employees) were more likely to offer employees insurance.

But in 2005 there was a steep drop-off nationally in the number of small companies offering insurance, even as the number ticked up in Massachusetts. Since then, the offer rate across all companies in the United States has stabilized at about 60 percent, compared to 76 percent in post-overhaul Massachusetts.

We will have a better sense of whether a shift similar to what happened in Massachusetts is occurring now in the whole country when the Kaiser Foundation releases its 2014 employer survey, in September. In the meantime, The Agenda will take a look at how Massachusetts's health care law has affected small businesses in the state, especially those offering coverage to employees for the first time. If you own a Massachusetts business and have a story about the law's impact on your company, please share it. Post a comment below, or send us an email.

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January 16, 2014 Thursday  
Late Edition - Final

Federal Judge Upholds Health Care Subsidies

BYLINE: By ROBERT PEAR

SECTION: Section A; Column 0; National Desk; Pg. 17

LENGTH: 753 words

WASHINGTON -- A federal judge rejected a legal challenge on Wednesday to a central part of President Obama's health care law, ruling that millions of low- and moderate-income people could obtain health insurance subsidies regardless of whether they bought coverage through the federal insurance exchange or in marketplaces run by the states.

Critics of the law had said that a literal reading of it would allow subsidies only in the 14 states that ran their own exchanges. But the judge, Paul L. Friedman of the Federal District Court here, said that was absurd and contrary to the whole purpose of the Affordable Care Act. 

''The plain text of the statute, the statutory structure and the statutory purpose make clear that Congress intended to make premium tax credits available on both state-run and federally facilitated exchanges,'' Judge Friedman said.

After analyzing the law and its legislative history, he said, ''Congress assumed that tax credits would be available nationwide'' and ''on any exchange, regardless of whether it is operated by a state'' or by federal officials.

The ruling is important because the federal government runs the exchange serving 36 states, which account for about two-thirds of the nation's population.

Ronald F. Pollack, the executive director of Families U.S.A., a liberal-leaning advocacy group, said the ruling was ''an important win for health care consumers across the country.''

Sam Kazman, general counsel of the Competitive Enterprise Institute, a libertarian advocacy group that is coordinating and helping finance the lawsuit, said the plaintiffs would appeal the decision.

From Oct. 1, when the exchanges opened, through Dec. 28, nearly 1.2 million people selected health insurance plans in the federal marketplace, and nearly a million chose plans in state exchanges.

About four-fifths of people choosing health plans at both levels of government qualified for subsidies that reduced their premiums. Subsidies may be available to people with annual incomes up to $45,960 for individuals and up to $94,200 for a family of four.

The lawsuit, Halbig v. Sebelius, was filed by several people in states that use the federal exchange: Tennessee, Texas, Virginia and West Virginia. They objected to being required to buy insurance even with subsidies to help defray the cost.

They said the health care law authorized subsidies specifically for insurance bought on ''an exchange established by the state.'' Congress, they said, provided subsidies in that way as an incentive for states to establish and operate exchanges, rather than leaving the task to the federal government.

However, Judge Friedman found no evidence of such a purpose. He quoted remarks on the Senate floor by Senator Max Baucus, Democrat of Montana and an architect of the law, who said in December 2009 that Congress was giving states a choice to set up their own exchanges or to allow the federal government to do so.

When federal officials create an exchange, Judge Friedman said, they ''stand in the shoes of the state.''

In voting for the Affordable Care Act, Democrats in Congress assumed that states would set up their own exchanges. But many Republican governors and state legislators balked, and opposition to the law became a rallying cry for the party.

Judge Friedman said the plaintiffs' argument seemed intuitively appealing. The section of the law providing health insurance subsidies, ''viewed in isolation, appears to support plaintiffs' interpretation'' because ''the federal government, after all, is not a state,'' he said.

But this reading of the law leads to ''strange or absurd results,'' the judge said, adding that courts must interpret statutes as a whole, not just isolated provisions.

The first page of the law declares the intent of Congress to ensure ''health care for all Americans.''

''Plaintiffs' proposed construction in this case -- that tax credits are available only for those purchasing insurance from state-run exchanges -- runs counter to this central purpose of the Affordable Care Act: to provide affordable health care to virtually all Americans,'' Judge Friedman said.

Thus, he said, the regulation in question, issued by the Internal Revenue Service in May 2012, was a reasonable interpretation of the law and was consistent with the intent of Congress to provide subsidies in the federal exchange as well as state exchanges.

Similar lawsuits, challenging subsidies in the federal exchange, have been filed by several Virginia residents and by state officials in Oklahoma and Indiana.

URL: http://www.nytimes.com/2014/01/16/us/judge-upholds-rights-to-subsidies-in-health-care-law.html

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March 24, 2017 Friday  
Late Edition - Final

Trump, Demanding Vote on Imperiled Health Bill, Tells G.O.P.: Now or Never

BYLINE: By JULIE HIRSCHFELD DAVIS, ROBERT PEAR and THOMAS KAPLAN; Jennifer Steinhauer, Emmarie Huetteman and Margot Sanger-Katz contributed reporting.

SECTION: Section A; Column 0; National Desk; Pg. 1

LENGTH: 1832 words

WASHINGTON -- President Trump issued an ultimatum on Thursday to recalcitrant Republicans to fall in line behind a broad health insurance overhaul or see their opportunity to repeal the Affordable Care Act vanish, demanding a Friday vote on a bill that appeared to lack a majority to pass.

The demand, issued by his budget director, Mick Mulvaney, in an evening meeting with House Republicans, came after a marathon day of negotiating at the White House and in the Capitol in which Mr. Trump -- who has boasted of his deal-making prowess -- fell short of selling members of his own party on the health plan.

House Speaker Paul D. Ryan emerged from the session and announced curtly that Mr. Trump would get his wish for a vote on Friday. Mr. Ryan refused to answer reporters' questions about whether he expected the measure to pass.

Although the House Republicans' closed-door meeting became a cheerleading session for the bill, their leaders braced for a showdown on the floor, knowing they were likely to be at least a handful of votes short of a majority for the health insurance bill and would need to muscle their colleagues to the last to prevail. 

Some conservatives were still concerned that the bill was too costly and did not do enough to roll back federal health insurance mandates. Moderates and others, meanwhile, were grappling with worries of their states' governors and fretted that the loss of benefits would be too much for their constituents to bear.

Mr. Ryan had earlier postponed the initial House vote that was scheduled for Thursday to coincide with the seventh anniversary of the Affordable Care Act's signing. Mr. Trump confronted the possibility of a humiliating loss on the first significant legislative push of his presidency.

At a White House meeting with members of the hard-line Freedom Caucus earlier on Thursday, Mr. Trump had agreed to the conservatives' demands to strip federal health insurance requirements for basic benefits such as maternity care, emergency services, mental health and wellness visits from the bill. But that was not enough to placate the faction, part of the reason that Thursday's vote was placed on hold.

As House leaders struggled to negotiate with holdouts in the hopes of rescheduling the vote, Mr. Trump sent senior officials to the Capitol with a blunt message: He would agree to no additional changes, and Republicans must either support the bill or resign themselves to leaving President Barack Obama's signature domestic achievement in place.

''We have a great bill, and I think we have a good chance, but it's only politics,'' Mr. Trump said earlier Thursday, as it was becoming clear that his negotiating efforts had failed to persuade enough members of his party to back the plan -- which was years in the making -- to repeal and replace the health law.

Privately, White House officials conceded that competing Republican factions were each demanding changes that could doom the effort, placing the measure in peril and Mr. Trump's chances of succeeding at a high-stakes legislative deal in jeopardy. With some of its demands in place, the Freedom Caucus ratcheted up its requests, insisting on a repeal of all regulatory mandates in the Affordable Care Act, including the prohibition on excluding coverage for pre-existing medical conditions and lifetime coverage caps.

Mr. Trump, who has touted his negotiating skills and invited the label ''the closer'' as the vote approached, was receiving a painful reality check about the difficulty of governing, even with his own party in power on Capitol Hill.

''Guys, we've got one shot here,'' he told members of the Freedom Caucus at a meeting in the Cabinet Room, according to a person present in the room who spoke on the condition of anonymity because the meeting was private. ''This is it -- we're voting now.''

''The choice is yes or no,'' Representative Joe Barton, Republican of Texas and a member of the Freedom Caucus, said on Thursday night. ''I'm not going to vote no to keep Obamacare. That'd be a stupid damn vote.''

Others were unconvinced.

Having secured Mr. Trump's acquiescence to eliminate the requirement that insurers offer ''essential health benefits,'' members of the Freedom Caucus pressed their advantage. While they did not specify precisely which regulations they wanted to eliminate, the section they wanted to gut requires coverage for pre-existing health conditions, allows individuals to remain on their parents' health care plans up to age 26, bars insurers from setting different rates for men and women, prohibits annual or lifetime limits on benefits, and requires insurers to spend at least 80 percent of premium revenue on medical care.

''We're committed to stay here until we get it done,'' said Representative Mark Meadows, Republican of North Carolina and the chairman of the Freedom Caucus. ''So whether the vote is tonight, tomorrow or five days from here, the president will get a victory.''

He said 30 to 40 Republicans planned to vote ''no''; House leaders can afford to lose only 22 in order to pass the bill.

But for every concession Mr. Trump made to appease critics on the right, he lost potential rank-and-file supporters in the middle, including members of the centrist Tuesday Group who had balked at the bill's Medicaid cuts and slashed insurance benefits. Moderate Republicans in that group went to the White House on Thursday but emerged unmoved in their opposition.

''There's a little bit of a balancing act,'' conceded Sean Spicer, the White House press secretary.

Representative Leonard Lance, Republican of New Jersey, said he still opposed the bill because he did not believe it would give people ''complete and affordable access'' to health insurance.

At the same time, a new estimate of the bill's cost and its impact on health coverage further soured the picture for wavering lawmakers. The nonpartisan Congressional Budget Office on Thursday issued a report on the revised version of the health care bill showing that it would cost more than the original version but would not cover more people. The report said the bill, like the original version, would result in 24 million fewer Americans having health insurance in 2026 than under current law.

But recent changes to the bill, made through a series of amendments introduced on Monday, would cut its deficit savings in half. Instead of reducing the deficit by $337 billion, the new version of the bill would save only $150 billion over the decade.

The budget office did not consider the effects of various additional changes that remain under negotiation, including eliminating benefit requirements and other health insurance regulations.

A Quinnipiac University national poll found that voters disapproved of the Republican plan by lopsided margins, with 56 percent opposed, 17 percent supportive and 26 percent undecided. The measure did not even draw support among a majority of Republicans; 41 percent approved, while 24 percent were opposed.

President Trump appealed to supporters to weigh in, assuring them in a video on Twitter, ''Go with our plan. It's going to be terrific.''

You were given many lies with #Obamacare! Go with our plan! Call your Rep & let them know you're behind #AHCA â[#x17e]¡ï¸ https://t.co/xAX4GJiO8z pic.twitter.com/qp90G49e0j -- President Trump (@POTUS) March 23, 2017

The chaotic process that unfolded on Thursday exposed Republicans to criticism that they were moving recklessly in a desperate bid to get their plan passed. Representative Raúl Labrador, Republican of Idaho and a Freedom Caucus member, said the party's leaders had tried to ram through the measure over their members' objections. He panned what he described as a ''brute force'' strategy that resembled the approach of former Speaker John A. Boehner, Republican of Ohio.

''It's better to get it right than to get it fast,'' Mr. Labrador said.

It was not clear that the changes that Mr. Trump has agreed to and those being demanded could survive. Under the strict budget rules being used to advance the bill, changes to the Affordable Care Act must affect federal spending or revenues. Regulatory measures that affect private health policies, not government programs like Medicaid, are highly likely to be challenged by Senate Democrats. If the Senate parliamentarian rules in the Democrats' favor, those changes in the House would be stripped from the bill.

The emerging power of the Freedom Caucus, a group that has been historically marginalized in policy making but a thorn in the side of leadership, is one of the surprises of the rushed health care debate. The group has been empowered by the addition of Mr. Mulvaney to the senior White House staff, and Mr. Trump's disengagement from policy details, coupled with his intense desire to score a win after a rocky start to his presidency.

Mr. Obama stepped into the fray on Thursday with a lengthy defense of his law on the seventh anniversary of its signing, and a call for bipartisan improvements.

''I've always said we should build on this law, just as Americans of both parties worked to improve Social Security, Medicare, and Medicaid over the years,'' he wrote in a mass email to followers. ''So if Republicans are serious about lowering costs while expanding coverage to those who need it, and if they're prepared to work with Democrats and objective evaluators in finding solutions that accomplish those goals -- that's something we all should welcome.''

The Affordable Care Act requires insurers to provide ''essential health benefits'' in 10 broad categories, including maternity care, mental health care, addiction treatment, preventive services, emergency services and rehabilitative services.

Mr. Spicer defended the removal of the ''essential health benefits'' regulations, saying that it would accomplish Mr. Trump's stated goal of reducing health care costs. ''Part of the reason that premiums have spiked out of control is because under Obamacare there were these mandated services that had to be included,'' Mr. Spicer said.

Family planning groups and advocates for women's rights criticized Republican plans to roll back these requirements.

''Paul Ryan and his House members are willing to sell out the moms of America to pass this bill,'' said Dawn Laguens, an executive vice president of the Planned Parenthood Federation of America.

Conservatives say the mandates, as interpreted in rules issued by the Obama administration, add to the costs of health insurance and make it difficult for insurers to offer lower-cost options to meet consumers' needs.

Democrats say that the purpose of insurance is to share risk, and that without federal requirements, insurers would once again offer bare-bones policies. Before the Affordable Care Act took effect, maternity coverage was frequently offered as an optional benefit, or rider, for a hefty additional premium.

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URL: http://www.nytimes.com/2017/03/23/us/politics/health-republicans-vote.html

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November 14, 2014 Friday

Facts & Figures: Americans Like Their 'Obamacare'

BYLINE: THE EDITORS

SECTION: OPINION

LENGTH: 126 words

HIGHLIGHT: Seventy-one percent of survey respondents said their coverage was good or excellent.

A large majority of Americans say they like the insurance coverage they obtained through government exchanges, which were set up by the Affordable Care Act. 

Via Politico

With the second round of Obamacare enrollment set to begin on Saturday, 71 percent said their coverage through the exchanges was good or excellent, according to a Gallup poll released Friday. Another 19 percent said the coverage was fair, while 9 percent rated it poorly.

The pollster notes that these marks are comparable to all who have health insurance. However, those newly insured through the exchanges are more satisfied with the cost of health care - with 75 percent saying so - versus 61 percent of all insured respondents who said they were satisfied with the cost of health care.

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October 20, 2015 Tuesday  
The New York Times on the Web

Many Low-Income Workers Say 'No' to Health Insurance

BYLINE: By STACY COWLEY

SECTION: Section ; Column 0; Business/Financial Desk; Pg.

LENGTH: 1390 words

JACKSONVILLE, N.C. -- When Billy Sewell began offering health insurance this year to 600 service workers at the Golden Corral restaurants that he owns, he wondered nervously how many would buy it. Adding hundreds of employees to his plan would cost him more than $1 million -- a hit he wasn't sure his low-margin business could afford.

His actual costs, though, turned out to be far smaller than he had feared. So far, only two people have signed up.

''We offered, and they didn't take it,'' he said. 

Evidence is growing that his experience is not unusual. The Affordable Care Act's employer mandate, which requires employers with more than 50 full-time workers to offer most of their employees insurance or face financial penalties, was one of the law's most controversial provisions. Business owners and industry groups fiercely protested the change, and some companies cut workers' hours to reduce the number of employees who would be eligible.

But 10 months after the first phase of the mandate took effect, covering companies with 100 or more workers, many business owners say they are finding very few employees willing to buy the health insurance that they are now compelled to offer. The trend is especially pronounced among smaller and midsize businesses in fields filled with low-wage hourly workers, like restaurants, retailing and hospitality. (Companies with 50 to 99 workers are not required to comply with the mandate until next year.)

''Based on what we've seen in the marketplace, we're advising some of our clients to expect single-digit take rates,'' said Michael A. Bodack, an insurance broker in Harrison, N.Y. ''One to 2 percent isn't unusual.''

Nationwide, the Affordable Care Act has significantly reduced the number of Americans without health insurance. Around 10.7 percent of the country's under-65 population was uninsured in the first three months of this year, down from 17.5 percent five years earlier, according to the National Health Interview Survey, a long-running federal study. Some 14 million previously uninsured adults have gained coverage in the last two years, the Obama administration estimates.

Most of those gains, though, have come from a vast expansion of Medicaid and from the subsidies that help lower-income people buy insurance through federal and state exchanges. Workers who are offered affordable individual coverage through their employers -- a group that the employer mandate was intended to expand -- are not eligible for government-subsidized insurance through the exchanges, even if their income would otherwise have qualified them.

But for those trying to get by on near-minimum wages, a plan that qualifies as ''affordable'' can still seem far out of reach.

That is the case for many of Mr. Sewell's workers. He employs 1,800 people at the 26 Golden Corral franchises he owns in six Southern and Midwestern states, and previously offered insurance only to his salaried management staff. In January, when the employer mandate took effect, he made the same insurance plan, with a bigger employer contribution, available to all employees working an average of 30 or more hours a week.

Running the math on his plan -- a typical one for the restaurant industry -- illustrates why a number of low-wage workers are falling through gaps in the Affordable Care Act.

The annual premium for individual coverage through the Golden Corral Blue Cross Blue Shield plan is $4,800. Mr. Sewell pays 65 percent for service workers, leaving them with a monthly cost of $140.

The health care law defines affordable employer-sponsored insurance as that priced at 9.5 percent or less of an employee's annual household income for individual coverage. (Because employers do not know how much money their workers' relatives make, there are several ''safe harbors'' they can use for compliance, including basing their calculation on only their own employees' wages.) Mr. Sewell's insurance meets the test, but $65 per biweekly paycheck is more than most of his workers are willing -- or able -- to pay for insurance that still carries steep out-of-pocket costs, including a $2,500 deductible.

Clarissa Morris, 47, has been a server at the Golden Corral here for five years, earning $2.13 an hour plus tips. On a typical day, she leaves the restaurant with about $70 in tips. Her husband makes $9 an hour at Walmart but has been offered only a part-time schedule there, without benefits. Their combined paychecks barely cover their rent and daily essentials.

''It's either buy insurance or put food in the house,'' she said. On the rare occasions that she gets sick, she visits a local clinic with sliding-scale fees. It costs her $25 for a visit, and $4 to fill prescriptions at Walmart.

Brad Mete, the managing partner of Affinity Resources, a staffing agency in Dania Beach, Fla., began offering insurance this year to most of his workers only because the law required it. He said the alternative, paying a penalty of about $2,000 per full-time employee, was unthinkable, ''That would put us out of business, in one swoop.''

Trying to persuade his hourly workers to buy the insurance is ''like pulling teeth,'' he said. His company's plan costs $120 a month, but workers making about $300 a week are reluctant to spend $30 of it on insurance.

The employer mandate has not yet had any noticeable effect on the number of workers enrolled in employer-sponsored health plans, according to a survey by Mercer, a human resources consulting firm. Most of the newly eligible appear to be obtaining coverage elsewhere, such as through the plan of a parent or spouse, or are continuing to go without, said Tracy Watts, a Mercer consultant.

A study by ADP, the payroll processing giant, found an income tipping point at which most employees who are eligible for health insurance will buy it: $45,000 a year.

Workers making $15,000 to $20,000 a year buy employer-sponsored individual insurance when it is offered only 37 percent of the time. That rate rises at every income increment ADP studied until $45,000, when it reaches 82 percent and levels off. Further income gains have virtually no effect on the rate, ADP found.

The study was conducted in 2013, before many of the Affordable Care Act's provisions took effect, but ADP's recent figures do not indicate significant changes in that pattern, according to Christopher Ryan, an ADP research executive.

Low participation can pose problems for employers, especially smaller ones. Insurers are reluctant to sell policies to companies with low enrollment, because they fear that only the sickest employees will buy coverage.

Until this year, most insurers would not cover groups that fell short of their minimum participation requirements. The Affordable Care Act struck down that policy -- a sea change for the industry -- by prohibiting minimum participation rules from being used to deny coverage to any employer with 100 or more workers. But there is a big loophole: Insurers are required to issue the policies, but they are not required to renew them.

Mario K. Castillo, a lawyer in Houston who has extensively studied the new law, said it was poorly understood in the industry, and a bureaucratic nightmare.

''They have to issue you a policy, but dropping it after one year is perfectly legal,'' he said. ''If you're in this space, you essentially have to shop for insurance every year.''

For employees, forgoing coverage can mean facing tax penalties. Ms. Morris said she was surprised by the $95 fee she had to pay this year for being uninsured in 2014. ''I had kind of heard about it, but I didn't think it was going to kick in until later,'' she said.

Around 7.5 million taxpayers paid the fine, according to a preliminary report by the Internal Revenue Service. That is significantly more than the three million to six million the government had forecast.

Low-income, full-time workers like Ms. Morris may prove to be some of the hardest people to bring into the ranks of the insured, said Gary Claxton, a vice president at the Kaiser Family Foundation, which conducts an annual study on employer health benefits.

''This is one of the outcomes of trying to keep employer-based coverage in place,'' Mr. Claxton said. ''These are folks that didn't have coverage before, and they're not being given much help to get coverage now.''

URL: http://www.nytimes.com/2015/10/20/business/many-low-income-workers-say-no-to-health-insurance.html

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December 3, 2013 Tuesday

October Medicaid Applications Far Outpace Enrollment Through Exchanges

BYLINE: Robert Pear

SECTION: US

LENGTH: 397 words

HIGHLIGHT: Of those who applied and were found eligible for the Medicaid or CHIP, slightly more than half were in states that have decided to expand Medicaid, as permitted under the Affordable Care Act, while 48 percent were in states that have not expanded Medicaid.

WASHINGTON - The Obama administration said Tuesday that 1.46 million people had applied and been found eligible for Medicaid or the Children's Health Insurance Program in October, far more than had selected a private health plan in the new insurance marketplaces. 

Of those found eligible for the Medicaid or CHIP, slightly more than half were in states that have decided to expand Medicaid, as permitted under the Affordable Care Act.

But 48 percent of the people found eligible for the programs - 697,000 people - were in states that have not expanded Medicaid.

The new health care law has produced many changes in the way states assess eligibility for Medicaid, and it provided money to states to upgrade antiquated computer systems. These changes, combined with publicity around the rollout of the federal law this fall, apparently contributed  to increases in the number of applications for Medicaid and in the number approved.

"In October, in states that are fully participating in the expansion of Medicaid coverage made possible by the law, we've seen a more than 15 percent jump in applications compared with the average monthly enrollment in July through September,'' the Department of Health and Human Services said. "This shows a real need and desire for coverage for low-income Americans.''

The report confirms expectations that many people who were eligible for Medicaid but not enrolled would come forward and seek coverage, even in states not expanding Medicaid.

For example, about 370,000 people were found eligible for Medicaid or CHIP last month in four states that have not expanded Medicaid: Florida (165,000), North Carolina (59,000), Pennsylvania (72,500) and South Carolina (73,300).

By contrast, in October, just 26,800 people selected private health plans in the new federal exchange, and 79,400 chose private plans through exchanges run by states.

States have decades of experience running Medicaid and carrying out changes in eligibility. In addition, since Medicaid is one of the biggest programs in state budgets, state Medicaid directors are often skilled, experienced managers, and their operation of the program is closely supervised by governors in almost every state.

The insurance exchanges, on the other hand, are entirely new, as are the computer systems, and congressional investigators have found huge deficiencies in management of the federal exchange.

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January 27, 2017 Friday  
Late Edition - Final

Health Law Ads Canceled Days Before Key Deadline

BYLINE: By ROBERT PEAR

SECTION: Section A; Column 0; National Desk; Pg. 19

LENGTH: 375 words

WASHINGTON -- The Trump administration is pulling back advertisements that encourage people to sign up for health insurance under former President Barack Obama's health care law.

The ads were to have run in the next few days of the annual open enrollment period, which ends on Tuesday. In the last few years, large numbers of consumers signed up just before the deadline.  

Under the Affordable Care Act, people who go without insurance are subject to tax penalties. But President Trump and Republicans in Congress are determined to repeal the law, including provisions that require most Americans to have insurance.

''The federal government has spent more than $60 million promoting the open enrollment period,'' a spokesman for the Department of Health and Human Services said Thursday. ''We have pulled back roughly $5 million of the final placement in an effort to look for efficiencies where they exist.''

However, the department continued to send email messages urging consumers to visit its insurance marketplace at HealthCare.gov.

''Final Deadline,'' said a typical email sent from the federal marketplace on Thursday. ''Our records show that you still need to submit a 2017 application -- before the final deadline on January 31. This year, millions of uninsured Americans have incomes that qualify them for reduced monthly costs on high-quality plans. Don't miss your final chance for 2017 health insurance.''

Since Nov. 1, more than 11.5 million people have signed up for insurance or had their coverage automatically renewed under the Affordable Care Act, federal officials said this month. More than 8.7 million of those consumers were in states that use HealthCare.gov as an enrollment portal.

Kevin J. Counihan, the former chief executive of the federal insurance exchange, accused the Trump administration of trying to ''sabotage open enrollment,'' and called the action ''outrageous.''

''We know that more young people enroll during the final days of open enrollment, but they need to be reminded of the January 31 deadline,'' Mr. Counihan said. ''Having health insurance is still law of the land. If the president and Republicans in Congress want to change that, they should come up with a plan and show it to the American people.''

URL: http://www.nytimes.com/2017/01/26/us/politics/donald-trump-obamacare-ads.html

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June 26, 2012 Tuesday

A Small Restaurant Gets a Big Increase in Health Premiums - and Misses the Tax Credit

BYLINE: ROBB MANDELBAUM

SECTION: BUSINESS; smallbusiness

LENGTH: 1064 words

HIGHLIGHT: The Herbfarm Restaurant seems like precisely the kind of small business that should benefit from the Affordable Care Act's tax credits.

With this post, The Agenda returns to our occasional series on how small companies are coping with providing health insurance. We're going to Woodinville, Wash., about a half hour north of Seattle, and The Herbfarm Restaurant. The Herbfarm, which grows many of its own ingredients in its garden and nearby fields, has also cultivated a distinguished national reputation since it opened more than two decades ago. The travel guide Frommer's once declared that the restaurant is "so famous and serves such unforgettable meals that people plan Seattle vacations around dinner here," but that hasn't made it any easier for its proprietors to provide affordable insurance to their employees.

THE OWNERS Ron Zimmerman and Carrie Van Dyck, both over 50.

THE COMPANY The Herbfarm Restaurant employs about 25 people year-round and a few more in the growing seasons. The restaurant also employs temporary "externs," visiting culinary school students who work in the restaurant and garden for a few months.

THE WAY THINGS WERE Until this year, the company paid half of the premiums and reimbursed half of the deductible cost for employees who worked 32 hours a week or more. Salaried employees were able to enroll three months after beginning work; hourly employees could join in six months. Employees who worked fewer than 32 hours could sign on to the company plans as well, but without premium reimbursement; and from time to time one or two would. Usually, about 10 people, including Mr. Zimmerman and Ms. Van Dyck, enrolled. In the plan every employee was offered last year, premiums were $363 a month, but the deductible was an astonishing $7,500.

HOW THINGS WENT AWRY Even given last year's deductible, Ms. Van Dyck said, "we've always had good coverage." In some years, the deductible has varied and the networks of doctors has changed, but the co-payment has held relatively steady. And every year, Ms. Van Dyck, who manages the restaurant's operations, has shopped for insurance with the help of an agent.

This year, her most recent insurer, Seattle-based Group Health Cooperative, demanded a 30-percent premium increase. Evidently "Group Health made a decision that they don't like small groups," Ms. Van Dyck said. (The director of Group Health's small group business offered the following statement: "We are committed to serving the small group market. We have been working with state leaders to increase the stability and affordability of insurance for small groups. We support Washington State exchange legislation that will provide more choice for small businesses and their employees.")

As for Ms. Van Dyck's agent, "his company name changed, and I'm pretty sure their priorities changed, too. Maybe they became small-group unfriendly" as well, she said. "This year he didn't bring us anything except health savings accounts, or we could stay with the same Group Health plan and pay a lot more." The H.S.A. plans required the full deductible to be met before prescription-drug benefits kicked in, and they required all family members to meet their deductibles before anyone could claim benefits. Moreover, she said, the agent insisted on extraneous requirements, like life insurance coverage. Eventually, Ms. Van Dyck found a new agent, who brought a menu of options from Aetna.

THE NEW PLAN Beginning in April, her employees could choose from three options: an H.S.A. with a $1,500 deductible (premiums are $411 a month), a plan with a high deductible ($5,000) but relatively low premiums ($310 a month), and a plan with a relatively low deductible ($1,500) but premiums that reach $450 a month. Ms. Van Dyck and Mr. Zimmerman chose the latter plan.

"I think it's really cool that we can choose the plan that's best for us," Ms. Van Dyck said, but she acknowledged that two employees, one of whom faced higher living expenses, elected to go without insurance rather than take the high-deductible plan. At the moment, eight other employees get insurance from spouses who work elsewhere, leaving 13 permanent and temporary staffers without any insurance at all.

THE PERILS OF THE SMALL GROUP The transition has not been easy. Though the restaurant has enrolled fewer than 10 employees for coverage in the past, the new policy required at least 10 employees to participate, and Ms. Van Dyck had only nine, including herself and her husband. Ultimately, to meet the enrollment requirement, she decided to fully subsidize insurance for a young employee who had declined to buy it.

At the same time, Ms. Van Dyck is no longer able to make distinctions among her employees. "We used to set our own rules, and now the insurance people are telling me who can be eligible," she said. "If I want to have the salaried people come on in three months, I have to bring everybody on in three months, and if I want to pay half the premium for full-time people, I have to pay it for everyone else, too." Now, all employees who work three-quarter time or are technically eligible to join after three months, and people who work fewer hours aren't able to sign up at all. But, she said, "our current agent says she has information about all sorts of plans that people could get on an individual basis."

THE AFFORDABLE CARE ACT Though the Herbfarm Restaurant would seem to be an ideal candidate for the health law's small-business tax credit, which phases out as the permanent payroll reaches 25 employees and the average wage reaches $50,000, the owners' accountant told them they could not take advantage of it -- the I.R.S. requires filers to calculate the credit in such way that some companies that fall below each threshold are nonetheless still disqualified. Moreover, Ms. Van Dyck said she suspected that it was uncertainty about how the new law could remake the health insurance market that caused the turmoil with her own insurer. And she acknowledged that she isn't sure how the law will affect her whether the Supreme Court upholds it or strikes it down. Nonetheless, she is hoping the Supreme Court will uphold the law. "I can't imagine that we wouldn't benefit" from the overhaul if it remains intact, she said. "The whole purpose is that we do benefit from it."

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May 27, 2012 Sunday

In Medicine, Falling for Fake Innovation

BYLINE: EZEKIEL J. EMANUEL

SECTION: OPINION

LENGTH: 619 words

HIGHLIGHT: We need to stop glorifying every new technology as an innovation. New matters only when it's proved better than what we had before.

THE sleek, four-armed "da Vinci" robot has been called a breakthrough technology for procedures like prostate surgery. "Imagine," the manufacturer says, "having the benefits of a definitive treatment but with the potential for significantly less pain, a shorter hospital stay, faster return to normal daily activities."

That's just the kind of impressive-sounding innovation that critics of the health care reform act say will be stifled by the new law, with its emphasis on cost control and the comparative effectiveness of new pills and devices. "Instead of encouraging innovation," wrote Senator Ron Johnson, Republican of Wisconsin, in The Wall Street Journal, "it stifles creativity."

The critics are right - if they're talking about innovations like the da Vinci robot, which costs more than a million dollars and yet has never been shown by a randomized trial to improve the outcomes of prostate surgery. Indeed, a 2009 study showed that while patients had shorter hospital stays and fewer surgical complications like blood loss when they underwent this kind of robotic surgery, they later "experienced more ... incontinence and erectile dysfunction." Similar problems are occurring with robotic surgery for other cancers.

In other words, this is a pseudo-innovation - a technology that increases costs without improving patients' health.

The Affordable Care Act will not reward this kind of innovation. But by providing incentives for hospitals to reduce infections, errors and readmissions, giving doctors more information on the comparative effectiveness of medical interventions and emphasizing preventive care over expensive services, the act will stimulate a panoply of true medical innovations. These may not be flashy; they might not even be visible to patients. But they will improve health care and lower costs.

For instance: checklists. A 2006 study showed that a five-item checklist - including hand-washing and cleaning a patient's skin - could reduce infection rates from intravenous catheters to nearly zero. According to the study, these infections cost an average of $45,000 per patient, and cause as many as 28,000 deaths among intensive care unit patients each year.

By the end of the decade, we will see many other true innovations - small and large, high-tech and non-tech. Diabetics' smartphone applications could transmit their glucose levels to doctors' offices; wireless home monitoring systems could be installed for patients with congestive heart failure; high-tech caps for drug bottles could alert patients' families if they forget to take their medications. There will also be many innovations in electronic health records. These aren't flashy robots, gleaming scanners or new pills, but there is already evidence that they will save money and improve care.

We have benefited tremendously from medical innovations like M.R.I. scanners, cardiac stents and powerful new drugs, and should celebrate the fact that the United States is the leader in developing medical technologies. But we need to stop glorifying every new technology as an innovation. "New" matters only when it's proved better than what we had before, when it prolongs survival, reduces side effects or improves quality of life - or maintains the current standard of care at a lower cost.

Health care reform may quash pseudo-innovations, but that simply directs capital and creativity away from technologies that don't improve outcomes or lower costs and toward ones that do. That should not be confused with killing innovation.

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July 16, 2013 Tuesday

A Bakery Is Relieved to Have the Employer Mandate Delayed

BYLINE: JULIE WEED

SECTION: BUSINESS; smallbusiness

LENGTH: 619 words

HIGHLIGHT: So far, the insurance plans Rachel Shein has reviewed have not seemed terribly attractive for her business.

With President Obama pushing back an important start date for the Affordable Care Act, giving companies with 50 or more full-time employees an extra year before they are required to offer health insurance to their workers, we decided to check in with Rachel Shein and her wholesale bakery, Baked in the Sun.

In March, Ms. Shein and her bakery, based near San Diego, were featured in a case study that looked at what she would have to do to comply with the new health care law. With insurance companies still developing their offerings for businesses like hers, Ms Shein was delighted to learn that the employer mandate was being delayed. "I was thrilled when I heard we had the extra time to watch and wait," she said. 

At the time the case study was written, Ms. Shein had been quite concerned about the potential effects of the law's implementation. "We saw it as a significant cost to our business, one we hadn't built into our business model," she said. Her participation in the case study led to appearances on several TV news programs, including on Fox Business and CNBC.

Initially, Ms. Shein estimated that she would have to pay $108,000 a year to include the 90 employees who are not currently covered by her company's health insurance. Her insurance broker now believes that when the final rates are published for next year, the cost will be higher than that.

Ms. Shein, though, will have to pay for only those employees who sign up for the plan she offers, and so far, the plans she has seen have not seemed terribly attractive. One sample plan, she said, included a $4,500 deductible, which Ms. Shein said "is too high for low-wage workers, so my employees may be better off going to the state-run market for individuals, which seems to have more options and better prices."

Insurance company offerings for businesses like hers are expected to evolve, Ms. Shein said, and she hopes better plans and choices become available, as they have on the individual exchange. Right now, Ms. Shein doesn't know the final costs or how many of her employees will sign up, so she has not been able to  estimate her expenses with any confidence. "It's still very messy," she said.

The delay is an opportunity for both companies and employees, Ms. Shein said, because it gives business owners more time to shop around and workers can take the year to see what is available on the exchange before they decide if they will take company-offered insurance.

Ms. Shein is also interested to see if the managers who are covered by her company's insurance plan find a better deal on the state-run market. She said she believed all workers should have health insurance, and she and her husband have wrestled with the problem for years. In her experience, she said, many of her employees are resistant to coverage that requires an employee contribution. "They are mostly young and healthy," she said, also noting that the individual penalty for not carrying insurance is low, "and they would rather have a bit more in their paycheck than health insurance."

For now, she plans to focus on running her baking company. "The recession has made us more efficient," she said. "We've automated more and focused on the most profitable parts of the business. I can't control the insurance rates, but I can make a great espresso mocha scone."

A previous version of this post reported incorrectly that it was Congress that had delayed the employer mandate.

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October 26, 2011 Wednesday

Insurers Weigh In on Health Care Law

BYLINE: REED ABELSON

SECTION: HEALTH

LENGTH: 547 words

HIGHLIGHT: The trade group for insurers files a legal brief on the health care law.

The health insurance industry is urging the Supreme Court to decide as quickly as it can whether the federal health care law is, in fact, constitutional and to consider what other parts of the law should be struck down if the individual mandate does not pass muster.

America's Health Insurance Plans, a Washington, D.C., trade group, filed its supporting brief on Tuesday about the case. The group represents the nation's health insurance companies, many of which oppose crucial provisions of the Affordable Care Act signed into law by President Obama last year.

The group argued that insurers need to know as soon as possible if the new law will be upheld. because businesses need to "make and implement numerous critical decisions now to ensure their ability to comply as requirements come into effect in the coming years."

Many of the law's most sweeping provisions go into effect in 2014. The Obama administration says the law is constitutional and has asked the Supreme Court to hear the case quickly. Several lower courts have issued differing opinions on the law, which was challenged in court by many states.

Right now, the insurers say they don't know if the whole law will be struck down or just parts of it or whether all of the legislation will be deemed constitutional. "All of this paralyzing uncertainty-among health plans, employers, government regulators and others - underscores the vital need for a prompt and conclusive resolution of the constitutional challenge to the individual mandate. AHIP therefore respectfully urges the court to grant review of that issue and to resolve it this term," the insurers say.

The insurers also say that without the individual mandate, which would require people to buy insurance, the law is essentially unworkable. They point out that there are concerns over adverse selection, where only the people who think they need coverage buy insurance, and cite numerous examples of failed efforts by the states.

"All of that evidence underscores the very real likelihood that implementation of ACA's market reforms in the absence of the individual mandate would confound the legislation's central goal of increasing the availability of affordable health care coverage. Congress, moreover, enacted the individual mandate in conjunction with its market reforms because it was acutely aware of the widespread difficulties that had arisen from the efforts of states to implement similar insurance market reforms without the economic counterbalance of an individual mandate," the insurers say.

Is the individual mandate constitutional? If the Supreme Court strikes it down, should the rest of the health care law be allowed to stand? Should everyone be required to have health insurance?

An earlier version of this post misstated the position taken by America's Health Insurance Plans on the overall federal health legislation. It is not asking the court to consider striking down the law altogether, but seeking consideration as to whether other pieces of the law should be overturned if the individual mandate is ruled unconstitutional.

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January 28, 2017 Saturday  
Late Edition - Final

Obamacare Sabotage

BYLINE: By VIKAS BAJAJ

SECTION: Section A; Column 0; Editorial Desk; Pg. 20

LENGTH: 307 words

The Trump administration doesn't have a plan to replace the Affordable Care Act, but it's already trying to sabotage the law. It has canceled advertisements meant to encourage people to pick insurance policies on HealthCare.gov ahead of the Jan. 31 sign-up deadline. 

This is a shameless attempt to drive down enrollment, especially among young people, who tend to wait until the last minute to get insurance but who are essential to the program because they tend to be healthier than older people and thus help spread the cost. Lower enrollment gives President Trump more ammunition in his fight against what he calls ''the failed Obamacare disaster.''

He and congressional Republicans have pledged to replace the law. And based on what lawmakers and Mr. Trump's choice to run the Department of Health and Human Services have said, the replacement could be a much inferior law that takes insurance away from millions and leaves others with bare-bones policies.

As of Christmas Eve, more than 11.5 million people had signed up on the federal and state health insurance exchanges, up nearly 300,000 from a comparable period a year earlier. The Obama administration had predicted total sign-ups of 13.8 million by the end of January.

The Trump administration says that by canceling the ads they are simply finding ''efficiencies where they exist.'' But officials who worked on the Affordable Care Act until just before the inauguration say that the ads had already been paid for. Even if some or all of the $5 million spent on those ads is refunded to the government, canceling them at this late stage is counterproductive and could prove very costly to the health care system and to people who don't get insurance.

Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today newsletter.

URL: http://www.nytimes.com/2017/01/27/opinion/obamacare-sabotage.html

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August 21, 2012 Tuesday  
Late Edition - Final

Investors In Health Care Seem to Bet On Incumbent

BYLINE: By ANDREW ROSS SORKIN;

SECTION: Section B; Column 0; Business/Financial Desk; DEALBOOK; Pg. 1

LENGTH: 891 words

Who is going to win the presidential election?You might want to ask Mark T. Bertolini. He just bet $5.7 billion on President Obama.

Mr. Bertolini is the chief executive of Aetna, which on Monday agreed to acquire Coventry Health Care, a huge provider of Medicare and Medicaid programs. His $5.7 billion bet makes a lot of sense if you believe that the Affordable Care Act - otherwise known as Obamacare - will not be repealed.

Mitt Romney has pledged to repeal the act "on my first day if elected," so any gamble that Obamacare stays intact could be fairly described as a wager that President Obama will remain in office. 

At a time when so many in the business community appear to be supporting Mr. Romney, it is telling that some businessmen and investors expect a different result - and are wagering more than rhetoric; they are staking their wallet on it.

It may be counterintuitive, but with the Standard & Poor's 500 up 9.5 percent in the last three months and the stock market over all at its highest point since the financial crisis, there is an argument to be made that investors writ large may be helping the incumbent to win. Intrade, an online market that allows investors to bet on political outcomes and other world events, shows that President Obama is favored to win, 57.3 percent to 42 percent.

"The best single predictor of presidential re-election results that we found was the percentage change in the stock market during the three years that preceded Election Day," Deepak Goel of the Socionomics Institute said in February when he released a study that was recently highlighted by Reuters. The study said that recent performance of the stock market was more important than gross domestic product, inflation and unemployment.

At a minimum, the stock market, which is an indicator of future earnings, seems to be in disagreement, at least somewhat, with the steady drumbeat of C.E.O.'s and investors who have said that President Obama's administration, in the words of Daniel Loeb, the outspoken activist hedge fund investor, "is openly hostile to most businesses and unable to articulate or implement policies to spark growth and reduce unemployment."

Mr. Loeb is a frustrated Obama voter who now backs Mr. Romney.

But take a look at some of his most recent investments in the health care field. In the last quarter, he reported in Securities and Exchange Commission filings, he picked up shares of Aetna, Cigna, Humana, UnitedHealth and WellPoint, among others. All of those companies stand to benefit while Obamacare remains in force; a repeal of the bill could send those shares reeling.

Mr. Bertolini of Aetna insisted on Monday that the deal was not dependent on who wins the White House. But he has to say that. If he believed Mr. Romney was going to win and he still wanted to buy Coventry, he would have waited until after the election and bought it at a sharp discount.

In a note to investors on Monday about Aetna's Coventry deal, an analyst at Barclays explained the rationale of it plainly as a way of "strategically positioning themselves to capitalize on further gains which may arise as a result of the election and health care reform."

Aetna is not the only company to make a bet on the White House. WellPoint agreed to acquire Amerigroup for $5 billion in July, just a little over a week after the Supreme Court's decision to uphold the Affordable Care Act. Before that, Cigna paid $3.8 billion for HealthSpring in another bet on the expansion of Medicaid and Medicare.

Companies like Aetna, WellPoint and Cigna have all gravitated to rivals with a foothold in government-sponsored programs because the prevailing view is that margins for private customers are going to steadily erode. According to Aetna on Monday, the acquisition of Coventry will "substantially increase Aetna's Medicaid footprint, creating more opportunity to participate in the expansion of Medicaid and to pursue high acuity positions as they move into managed care." Aetna's revenue from the government will jump to 30 percent from 23 percent.

In fairness, it is possible to argue that the election will be immaterial to the future of the Affordable Care Act. Even if Mr. Romney wins the presidency, depending on which parties are in the House and Senate, the act may be impossible to roll back.

"Some will argue that with the election just over two months away, the company could have been more prudent in its timing," the Barclays analyst wrote. "Our take is that the election, reform and other potential legislative issues will have little impact on this transaction."

David Einhorn of Greenlight Capital recently made the contrarian case that companies like Cigna would actually do better if the law were to be repealed, ostensibly because of the margin compression that is likely as a result of the new law.

"While the stocks are already cheap, there is the additional unpriced upside in the possibility that the election changes the political landscape, resulting in a possible modification or repeal of Obamacare," he wrote in a letter to investors last month.

Still Mr. Einhorn, through smarts or luck, made a big investment in Coventry in the last quarter. With the sale to Aetna, irrespective of his investment thesis, Mr. Einhorn's firm just made about $72 million.

This is a more complete version of the story than the one that appeared in print.

URL: http://dealbook.nytimes.com/2012/08/20/investors-in-health-care-seem-to-bet-on-incumbent/

LOAD-DATE: August 21, 2012

LANGUAGE: ENGLISH

GRAPHIC: PHOTO: Mark Bertolini is the chief executive of Aetna, which agreed to acquire Coventry Health Care, a provider of Medicare programs. (PHOTOGRAPH BY ANDREW HARRER/BLOOMBERG NEWS) (B4)

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March 26, 2012 Monday  
Late Edition - Final

Fighting to Control the Meaning of ''Obamacare''

SECTION: Section A; Column 0; National Desk; Pg. 12

LENGTH: 687 words

On Monday, the Supreme Court will begin three days of arguments over the constitutionality of the Affordable Care Act. The act is often called ''Obamacare,'' primarily by Republicans, as a term of disdain. Democrats have tried to limit the term's use to reshape perceptions, but that has been a tough sell. Grant Barrett, a vice president for the American Dialect Society, says it is almost impossible to persuade people to discontinue the use of a political word. ''It's an invitation to have your heart broken. You forbid it, and they start writing it on the bathroom stalls.'' Now Democrats seem to be embracing the term, launching a Twitter campaign that seeks to build positive associations for it.

2007 

MARCH Jeanne Schulte Scott, a lobbyist, writes in the journal Healthcare Financial Management: ''We will soon see a 'Giuliani-care' and 'Obama-care' to go along with 'McCain-care,' 'Edwards-care,' and a totally revamped and remodeled 'Hillary-care' from the 1990s.''

MAY At a campaign speech in Iowa, Mitt Romney criticizes Democratic health care plans, saying, ''The path of Europe is not the way to go. Socialized medicine. Hillarycare. Obamacare.''

2008

APRIL 30 A spokesman for FreedomWorks, a group affiliated with the Tea Party movement, writes on the group's blog: ''Barack Obama is busy promoting his own version of HillaryCare. You can call it ObamaCare.'' MAY At a campaign speech in Iowa, Mitt Romney criticizes Democratic health care plans, saying, ''The path of Europe is not the way to go. Socialized medicine. Hillarycare. Obamacare.''

2009

JULY 8 Quoting an editorial in The Wall Street Journal, Roy Blunt of Missouri, then a congressman, and Senator Jon Kyl of Arizona enter the word into the Congres-sional Record for the first time.

2010

MARCH 23 Mr. Obama signs the Affordable Care Act into law.

DECEMBER The Department of Health and Human Services buys advertising on Google so that a link to its web site, healthcare.gov, appears at the top of searches for ''Obamacare.'' An official tells Politico that this is part of an effort to ''get accurate informa-tion to people about the new law.''

2011

FEB. 11 Representative John Conyers Jr. of Michigan says that while opponents use ''Obamacare'' in a derogatory sense, he also uses it because ''it's going to go down in history as a major accomplishment of the president's.''

JAN. 7 Representative Steve King of Iowa uses ''Obamacare'' more than 60 times in a speech. In the Congressional Record, Mr. King has used the word nearly five times as often as any other lawmaker.

FEB. 18 Representative Debbie Wasserman Schultz of Florida argues against the use of ''Obamacare'' on the House floor. ''It is meant as a disparaging reference to the president of the United States, and it is clearly in violation of the House rules against that.''

JUNE 12 The Republican presidential candidate Tim Pawlenty uses ''Obamneycare'' to link the plan to one Mr. Romney signed as governor of Massachusetts.

AUG. 15 Mr. Obama uses the word in a speech, adding, ''I have no problem with people saying 'Obama cares.' I do care. If the other side wants to be the folks who don't care? That's fine with me.''

ON THE CAMPAIGN TRAIL Republican candidates use ''Obamacare'' to fire up the base, promising to repeal the law.

Bachmann 236

Romney 84

Santorum 78

Gingrich 49

Uses of ''Obamacare'' in debates, television interviews and major speeches from May 1, 2011, to March 11, 2012, (or until each candidate dropped out), as transcribed by Federal News Service.

OCTOBER Democrats object to the use of the term ''Obamacare'' in mailings paid for with Congres-sional funds, saying that it violates a rule against using the mailings for political reasons.

2012

MARCH 23 The Obama campaign posts on Twitter, ''If you're proud of Obamacare and tired of the other side using it as a dirty word, complete this sentence: #ILikeObamacare because...''

MARCH Number of times ''Obamacare'' was used each month by members of Congress as recorded in the Congressional Record. MARCH Number of times ''Obamacare'' has been used from March 1 to 23, according to transcripts kept by ShadowTV.

Fox News 320

MSNBC 180

URL: http://www.nytimes.com

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ShadowTV (TV counts)
Federal News Service transcripts (2012 candidate mentions)
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May 27, 2013 Monday  
Late Edition - Final

Partisan Gridlock Thwarts Effort to Alter Health Law

BYLINE: By JONATHAN WEISMAN and ROBERT PEAR

SECTION: Section A; Column 0; Business/Financial Desk; Pg. 1

LENGTH: 1459 words

WASHINGTON -- When he talks to Republicans in Congress, Scott DeFife, a restaurant industry lobbyist, speaks their language: President Obama's health care law is a train wreck well down the track. There will be collateral damage if changes are not made. Friends of the industry cannot sit back and let that happen.

Speaking to Democrats, he puts on his empathy hat: The Affordable Care Act is the law of the land. Its goal of universal insurance coverage is laudable, but its unintended consequences will hurt the cause.

Almost no law as sprawling and consequential as the Affordable Care Act has passed without changes -- significant structural changes or routine tweaks known as ''technical corrections'' -- in subsequent months and years. The Children's Health Insurance Program, for example, was fixed in the first months after its passage in 1997. 

But as they prowl Capitol Hill, business lobbyists like Mr. DeFife, health care providers and others seeking changes are finding, to their dismay, that in a polarized Congress, accomplishing them has become all but impossible.

Republicans simply want to see the entire law go away and will not take part in adjusting it. Democrats are petrified of reopening a politically charged law that threatens to derail careers as the Republicans once again seize on it before an election year.

As a result, a landmark law that almost everyone agrees has flaws is likely to take effect unchanged.

''I don't think it can be fixed,'' Senator Mitch McConnell of Kentucky, the Republican leader, said in an interview. ''Everything is interconnected, 2,700 pages of statute, 20,000 pages of regulations so far. The only solution is to repeal it, root and branch.''

Senator Max Baucus, Democrat of Montana and one of the law's primary authors, said: ''I'm not sure we're going to get to the point where it's time to open the bill and make some changes. Once you start, it's Pandora's box.''

As the clock ticks toward 2014, when the law will be fully in effect, some businesses say that without changes, it may be their undoing.

''Are we really going to put the private sector in a situation where there's a real potential mess for posturing points?'' Mr. DeFife asked.

This is not the usual way ambitious laws are carried out, but given the politics of the Affordable Care Act, ''we cannot use any of the normal tools to resolve ambiguities or fix problems,'' said Sara Rosenbaum, a professor of health law and policy at George Washington University.

The enactment of Medicare in 1965 was followed by changes in 1967, and again in 1972. In November 1986, President Ronald Reagan signed a landmark immigration bill that offered legal status to many unauthorized immigrants. Two years later, Congress made dozens of ''technical corrections.''

The Social Security Act of 1935 was followed by the family protection program of 1939, which clarified that benefits could be claimed not just by retirees but also by dependents and survivors of covered workers.

Three years after the Affordable Care Act was enacted, an extensive list of possible fixes and clarifications has piled up. For example, Families USA, a liberal advocacy group and strong supporter of the law, would like to see more money to pay for ''navigators'' to help enroll the uninsured in the new health care marketplaces.

One provision of the statute allows low-income workers to opt out of employer-sponsored care -- and into federally subsidized exchanges -- if their share of the premium for workplace insurance tops 9.5 percent of household income. But that is calculated based on the individual worker's costs, not the total family's costs, said Ronald F. Pollack, the executive director of Families USA. It is a ''glitch,'' he said, that should easily be fixed.

But it will not be, lawmakers and lobbyists say. ''I don't believe in this Congress, anything of real substance is likely to be passed,'' Mr. Pollack said.

Senators Richard M. Burr of North Carolina and Susan Collins of Maine, both Republicans, are trying to modify the law, to make it easier for small and midsize businesses to comply.

''Listen, this is statute,'' Mr. Burr said with a tone of exasperation. ''The president's not going to sign a repeal bill. I think it's prudent to try'' to make changes.

But they are facing the same hands-over-the-ears reluctance that business lobbyists and others are finding. The last consideration of the health care law came on May 16, when the House voted to repeal it, the 37th time the House has voted to do so. Those bills have died in the Senate, which is controlled by Democrats.

A coalition of large retailers, restaurant chains and temporary staffing companies, along with their powerful Washington trade associations, says it accepts the pillars of the law. But the group, calling itself Employers for Flexibility in Health Care, or E-Flex, is pressing for significant changes.

The law's definition of a full-time worker has to be raised from someone working 30 hours a week, E-Flex says, noting that restaurants, retailers and other businesses are already looking at cutting many employees' hours to 29 to avoid having to offer the health care coverage mandated by the law. The group wants the definition raised to 40 hours. They also say that the definition of a large employer -- with all that entails for the requirements for health insurance -- needs to rise from 50 full-time employees or ''full-time equivalents,'' which could be a combination of several part-time workers.

They would also like a grace period into 2014 to comply with the law before penalties are assessed for not offering insurance that comports with the law's mandates. And they want Congress to drop a provision requiring the automatic enrollment of new employees into a health care plan for any company with more than 200 full-time workers.

''Key definitions in the law must be changed,'' Marshall L. Conrad, chairman of Libby Hill Seafood Restaurants in Greensboro, N.C., pleaded at a recent Congressional hearing.

Health insurers are focused on another goal: repealing a new tax on insurance companies that takes effect next year. The tax is expected to raise more than $100 billion over 10 years. Insurers say the cost will be passed on to consumers and businesses in the form of higher premiums.

Concerns over the law's fine print are shared even among some of its architects. As the Affordable Care Act neared completion, the Obama administration and some Democrats in Congress drafted a proposed compromise to resolve differences between the House and Senate versions and smooth rough edges. Under that version, the marketplaces that people would be able to use next year to buy insurance, often at subsidized rates, were going to be national in scope, not state by state.

A provision that takes back subsidies if someone's income rises in a year was going to be softened. According to a former White House official involved in the drafting, Democrats debated the 50-employee definition for large businesses and were open to additional flexibility for seasonal workers and teenage employees.

That all disappeared when Massachusetts elected Scott Brown to the Senate in January 2010. The Democrats lost their filibuster-proof majority. House Democratic leaders saw no alternative but to accept the Senate-passed bill as written, with some changes to follow in a hastily drafted bill that passed under rules that prohibited a filibuster.

As a result, a back-room conference, where changes could be considered in private, never happened. Consequently, said E. Neil Trautwein, a health care lobbyist for the National Retail Federation, ''the edges don't quite line up.''

''We're beyond caring who provides employer relief at this point,'' he said. ''We just want the relief.''

The obstacles are huge, beginning, Republicans say, with President Obama, who has publicly said employers face no significant problems carrying out the legislation.

''For the 85 to 90 percent of Americans who already have health insurance, this thing has already happened, and their only impact is that their insurance is stronger, better, more secure than it was before. Full stop. That's it. They don't have to worry about anything else,'' the president told reporters last month.

Many pro-business Republicans appear no more receptive. Senator Johnny Isakson, Republican of Georgia, acknowledged the push to change the 30-hour rule for full-time workers and the 50-employee threshold for large businesses. But he said raising the hour cutoff to 35 would anger some other groups of employers.

''The reality of the ACA being on the doorstep of becoming law is it's going to begin collapsing under its own weight,'' Mr. Isakson said. ''I'm not so sure there's enough individual fixes to make the law more manageable.''

URL: http://www.nytimes.com/2013/05/27/us/politics/polarized-congress-thwarts-changes-to-health-care-law.html

LOAD-DATE: May 27, 2013

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GRAPHIC: PHOTOS: ''The only solution is to repeal it, root and branch,'' said Senator Mitch McConnell, Republican of Kentucky, the minority leader. (PHOTOGRAPH BY DREW ANGERER FOR THE NEW YORK TIMES)
Unlike many Republicans, Senator Richard Burr of North Carolina is trying to modify the law. (PHOTOGRAPH BY WIN McNAMEE/GETTY IMAGES) (B2)

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The New York Times

December 24, 2016 Saturday  
Late Edition - Final

Republicans Are in Denial on Health Care

BYLINE: By THE EDITORIAL BOARD

SECTION: Section A; Column 0; Editorial Desk; EDITORIAL; Pg. 18

LENGTH: 595 words

Republican critics of the Affordable Care Act have long described it as a house of cards on the verge of collapse. And they continue to be wrong. A record number of people have signed up for health insurance for 2017 on the federal exchanges created by the 2010 law.

Nearly 6.4 million people had signed up for coverage as of Monday, which is about 400,000 more than at a similar point last year. Among them were two million people who did not participate in 2016, some of whom might have previously been covered through an employer. The number of enrollees does not include many millions of people whose policies will be automatically renewed or who live in states like California, Minnesota and New York that have their own marketplaces.  

By the time open enrollment ends early next year, the Department of Health and Human Services estimates 13.8 million people will have signed up nationwide. The percentage of Americans without insurance is steadily declining, hitting a record low of 9.1 percent in 2015, the most recent year reported.

If President-elect Donald Trump and Republican leaders in Congress carry out their promise to repeal the law, they will be taking away health insurance from millions of people -- the A.C.A. also expanded Medicaid to cover about 14 million more low-income and poor people.

When the Obama administration announced in October that premiums would rise by 25 percent on average for midlevel plans on the federal exchanges, Republicans predicted that this would doom the system. They ignored the fact that most people would not have to pay more because federal subsidies would rise to account for the higher premiums charged by private insurers. About 77 percent of people eligible for the coverage on the exchanges can find policies for $100 a month or less.

Still, the cost of insurance, deductibles and co-payments is too high for many people, especially middle-class families that earn too much to qualify for subsidies. But the solution is not to take away the benefits of the law but to strengthen it. Costs could be lowered if more young and healthy people were encouraged to sign up to spread costs over a larger pool of people.

There is growing evidence that the law is working in other ways, too. The proportion of people who did not see a doctor because they couldn't afford to fell by at least two percentage points between 2013 and 2015 in 38 states and the District of Columbia, according to a new study by the Commonwealth Fund. That helps explain why only a quarter of Americans surveyed by the Kaiser Family Foundation said the law should be scrapped.

If lawmakers are moved by nothing else, they should think about the political costs of repealing the Affordable Care Act or crippling it with piecemeal changes. Many of the people who benefit from health reform live in states that voted for Mr. Trump and down-ballot Republicans. The Kaiser foundation estimated that residents of Florida received $5.2 billion in subsidies to buy health insurance as of last March, more than in any other state. More than 600,000 people in Ohio are enrolled in Medicaid thanks to the law. And in Texas, there are 4.5 million people with pre-existing conditions who cannot be denied coverage under the law, or charged higher prices.

Treating the Affordable Care Act as a punching bag during a political campaign is one thing. But it is quite another to destroy a law that is helping so many people.

Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today newsletter.

URL: http://www.nytimes.com/2016/12/23/opinion/republicans-are-in-denial-on-health-care.html

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The New York Times

August 20, 2016 Saturday  
Late Edition - Final

U.S. Health Officials Move to End Duplicate Coverage

BYLINE: By ROBERT PEAR

SECTION: Section A; Column 0; National Desk; Pg. 9

LENGTH: 938 words

WASHINGTON -- The Obama administration is moving to end duplicate coverage for tens of thousands of people who are enrolled in Medicaid and simultaneously receiving federal subsidies to help pay for private health insurance under the Affordable Care Act.

In the last few days, consumers around the country have received letters warning, in big black type: ''People in your household may lose financial help for their marketplace coverage.''  

The unsigned letters from the federal insurance exchange tell consumers that they ''should immediately end marketplace coverage with premium tax credits for each person'' in the household who is also enrolled in Medicaid or in the Children's Health Insurance Program.

If they fail to act, the administration says, it will unilaterally cut off any financial assistance they receive to help pay insurance premiums, deductibles and other out-of-pocket medical costs.

The action, supervised by Sylvia Mathews Burwell, the secretary of health and human services, comes more than nine months after congressional investigators from the Government Accountability Office said they had discovered the potential for duplicate coverage, with double payment.

The potential is significant because low-income people can switch back and forth between Medicaid and subsidized private coverage as their circumstances change.

The Affordable Care Act created the online marketplaces, where consumers can obtain subsidies for health coverage, and it expanded Medicaid to cover millions of adults without children. The Congressional Budget Office estimates that the subsidies and the expansion of Medicaid together cost about $100 billion this year.

State officials administer the Medicaid program, but federal officials run the insurance exchanges for most states. ''It is often difficult for the two levels of government to exchange information in real time because they use different computer systems,'' said Sara Rosenbaum, a professor of health law and policy at George Washington University.

The Obama administration identified people who were receiving both Medicaid and tax-credit subsidies by comparing records of the federal marketplace with enrollment files maintained by state Medicaid agencies. A similar exercise in the spring found 88,000 people with ''dual enrollment,'' but the administration did not take action against them.

Eligibility for the two programs can change because of changes in family size, household income or other factors. Information in federal and state files may, in some cases, be out of date. State agencies do not always notify the federal marketplace when they find a person eligible for Medicaid. Indeed, beneficiaries are supposed to notify the marketplace, according to HealthCare.gov.

Republicans in Congress say that in its desire to increase enrollment, the administration has been lax in verifying consumers' eligibility for subsidies.

''Federal officials have a legal and ethical duty to be good stewards of federal dollars,'' said Representative Joe Pitts, Republican of Pennsylvania and chairman of the Energy and Commerce subcommittee on health.

But Judith Solomon, a vice president at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group, said it was not right to view consumers with Medicaid and tax credits as ''double dippers.''

''In all likelihood,'' she said, ''they are not using both forms of coverage. People may not realize they have both and may not know how to stop the marketplace coverage. There's really no advantage to double dipping here. It's not like you get money in your pocket from either of these programs. They are vendor payment programs.''

Most people who obtain insurance through the exchanges also receive subsidies to help pay the premiums, and in most cases, the Treasury pays those subsidies directly to insurance companies. Many of the same companies have contracts with state Medicaid agencies to manage care for Medicaid beneficiaries, and from 2014 to 2016, the federal government pays the full cost of coverage for newly eligible beneficiaries.

Thus, the federal government may be paying twice for the same person if the person is in both Medicaid and a subsidized insurance policy bought through the marketplace.

''We really don't want this to continue because it's basically money going down the drain,'' said Ms. Solomon, a strong supporter of the health law.

Medicaid beneficiaries generally have less income than residents of the same state who buy insurance in the marketplace. Medicaid provides many services that commercial insurers do not cover, and people usually pay less under Medicaid than they would for the same services under a subsidized private health plan.

In states that expanded eligibility, Medicaid has also been more successful than the exchanges in signing up people for insurance.

The Senate majority leader, Mitch McConnell, Republican of Kentucky, questioned the administration's plans for a marketing campaign to promote enrollment under the Affordable Care Act this fall. In a letter to Ms. Burwell on Friday, he asked how much would be spent on the campaign and where the money would come from.

Mr. McConnell suggested in the letter that the money might be better spent combating the Zika virus than ''propping up the failed Obamacare exchanges.''

Administration officials said that expanding insurance coverage and preventing the spread of Zika were both high priorities for President Obama.

Follow The New York Times's politics and Washington coverage on Facebook and Twitter, and sign up for the First Draft politics newsletter.

URL: http://www.nytimes.com/2016/08/20/us/politics/affordable-care-act-medicaid-duplicate.html

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May 20, 2011 Friday  
The New York Times on the Web

Nursing Home Workers

SECTION: Section ; Column 0; Editorial Desk; LETTER; Pg.

LENGTH: 227 words

To the Editor:

''Nursing Homes Seek Exemptions From Health Law'' (front page, May 16) highlights one of the great ironies of our health care system: nearly one million nursing assistants and home care aides provide essential care every day, but have no health coverage themselves. 

According to P.H.I.'s latest analysis, the expansion of Medicaid under the Affordable Care Act could provide coverage to an additional 370,000 of these direct-care workers.

Demand for direct-care workers is growing dramatically as our population ages; in fact, direct care may soon be our nation's single largest occupation.

These workers provide essential services, keeping elders safe, secure and healthy. Yet unlike most workers, those who care for the elderly and people with disabilities in their homes are excluded from the minimum-wage and overtime protections of the Fair Labor Standards Act.

Our nation will not be able to build a stable elder-care work force without adequate public resources to ensure that direct-care workers receive a living wage and health coverage. Simply maintaining the status quo by exempting nursing homes from the requirements of the Affordable Care Act is not a solution.

CAROL REGAN Washington, May 16, 2011

The writer is director of health care for health care workers and government affairs director at P.H.I. (Paraprofessional Healthcare Institute).

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The New York Times

February 5, 2015 Thursday  
Late Edition - Final

Two Million Signed Up for Insurance on Exchange

BYLINE: By ANEMONA HARTOCOLLIS

SECTION: Section A; Column 0; Metropolitan Desk; Pg. 20

LENGTH: 583 words

About two million New Yorkers have signed up for insurance under the Affordable Care Act, with three out of every four of them poor enough to qualify for Medicaid, according to figures released Wednesday by the Cuomo administration.

While Gov. Andrew M. Cuomo heralded the overall numbers as a sign of the success of the program, having such a large proportion on Medicaid, which is funded by the government, could impose a heavy new burden on public finances.

But insurance experts said they expected the impact of the new Medicaid enrollment to be mitigated by the greater access to health care. In other words, they said, having Medicaid coverage would give people access to primary care that could keep them from developing a chronic disease or becoming catastrophically sick and ultimately costing the system even more. 

''Theoretically, could these numbers of people eventually push that Medicaid number up higher? Yes,'' James R. Tallon Jr., president of the United Hospital Fund, said on Wednesday.

But, he added: ''Having most people insured is the key to controlling long-term cost growth because it means you can manage care in a more effective way.''

By and large, experts said, those signing up for private insurance on the state's Affordable Care Act health exchange are people who were priced out of the market before. The law raised the income ceiling for Medicaid eligibility in New York and other states that accepted the expansion of the program; a family of four can now earn about $33,000 and still qualify. Many people who earn too much for Medicaid can get subsidies to help them buy private insurance.

Though Republicans in Congress have criticized the public costs and tried several times to repeal the law, which was passed in 2010, President Obama has vowed to veto any attempt to overturn it.

A new federal policy expanding the ability of immigrants to remain in the United States may further swell the insurance rolls, Mr. Tallon said. But he said the policy was probably too new to have affected this year's numbers.

Governor Cuomo also took a positive view, saying in a statement that ''these numbers are a testament to our progress in helping those without coverage find a plan that works for them.''

Mr. Cuomo has said, however, that the state needs ''a dedicated and sustainable revenue source'' to keep the exchange going. In his executive budget, he is proposing a surcharge of up to $25 a year on health insurance premiums for coverage both inside and outside the exchange.

Leslie Moran, senior vice president of the New York Health Plan Association, an insurance industry group, said Wednesday that the surcharge was ''a very bad idea.''

''Taxing insurance only makes it more costly and therefore, less affordable,'' Ms. Moran said. ''If affordable health coverage is the goal here in New York, the new 'exchange tax' should be dropped.''

Private coverage has gone up by 133,000 so far this year and Medicaid enrollment by 297,000. About 15 percent of those who bought private coverage last year have not renewed, possibly because they found the premiums too high or they obtained coverage through their employers.

Enrollment is not yet over for the year; the deadline is Feb. 15. Those who do not enroll by that date will have to wait until 2016 for coverage, unless they have experienced a life-changing event, like marriage or the birth of a child.

This is the first year that people who do not have insurance can be penalized for it on their taxes.

URL: http://www.nytimes.com/2015/02/05/nyregion/two-million-signed-up-for-insurance-on-exchange.html

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(Economix)

November 13, 2013 Wednesday

The Slow Death of the Employer Mandate

BYLINE: CASEY B. MULLIGAN

SECTION: BUSINESS; economy

LENGTH: 820 words

HIGHLIGHT: A Massachusetts precedent indicates that when business is given time to mount opposition, an employer mandate for health coverage may not be viable, an economist writes.

Casey B. Mulligan is an economics professor at the University of Chicago. He is the author of "The Redistribution Recession: How Labor Market Distortions Contracted the Economy."

Students of health reform can be informed and entertained by revisiting a book by the health reform champion John E. McDonough.

As a member of the Massachusetts House of Representatives from 1985 to 1997, Mr. McDonough had worked for state health reform well before the now famous Romneycare health reform of 2006. During that time he also earned a doctorate in public health. 

Like many other former legislators, he wrote a book about his experiences and relationships in office. "Experiencing Politics" (published 13 years ago) organizes his stories around social science models of the political process, including the principal-agent model and punctuated equilibrium theory.

The models are known by fancy phrases in the academic literature, but Mr. McDonough quickly brings them down to earth with explanations that are nontechnical and addressed to the general public. His stories are engaging and bring the models alive, even to social scientists who have seen the models on paper, yet may be dubious that they have much practical value.

Mr. McDonough is not trained as an economist, but usually shows good economic instincts in the book (though he does not mention that per-employee penalties and minimum wages might reduce employment among low-skill workers).

Why is politics so contentious and polarized these days? Mr. McDonough explains that there's a lot at stake: "We invest enormous authority and trust in our government" and "we give our legislatures remarkable powers to pass laws that govern our own behaviors, from the trivial to the profound."

Of particular interest today are his Chapters 6 and 7 on Massachusetts health legislation between 1988 and 1997. Mr. McDonough describes how the state's previous system of hospital rate regulation had been put in place for the purpose of controlling medical spending and how he believes it might have worked for a time.

But he says the academic studies on which he relied became outdated. "I didn't see it coming," he says, adding, "Massachusetts government lost the ability to manage its hospital regulatory system with discipline and integrity." He and other legislators concluded that "market-based contracting, organized around managed care, could correct the worst aspects of market failure, not perfectly but far better than regulation."

Mr. McDonough describes how Gov. Michael Dukakis's 1988 law sought to achieve universal coverage in Massachusetts with a legislative package that included a $1,680 penalty (per employee, per year) on employers who did not provide health coverage to their employees. Adjusted for inflation, that would be like proposing a $2,863 penalty in 2006, when Romneycare was passed with a mere $295 employer mandate.

The Dukakis package passed narrowly, and to gain legislative approval the final law delayed the employer mandate's implementation by four years. Does that sound familiar? The national Affordable Care Act was passed in 2010, with an employer mandate to begin in 2014.

Mr. McDonough describes how those four years gave Massachusetts employers time to organize their opposition. Moreover, as 1992 approached, the Massachusetts labor market was weak. Arguably both of these things happened nationally between 2010 and 2013.

As a legislator, Mr. McDonough met with business executives to respond to their concerns over health reform. He recalls one of those meetings where "sitting quietly through my presentation was the owner of a Domino's Pizza shop." The shop owner explained: "I compete against pizza stores that pay everything and everyone under the table. I pay unemployment, worker's comp, FICA, you name it, and you want to add one more thing that I have to dig up while my competitors pay none of those things? Come on."

Mr. McDonough had no reply to alleviate that concern. With a few months to go until the originally scheduled implementation, Massachusetts lawmakers decided to delay the Dukakis employer mandate for three years. It would be delayed two more times and then, in exchange for business community support for a coverage expansion for children, ultimately repealed.

On the national level, while Congress was not consulted, with six months to go before the originally scheduled implementation, the Obama administration delayed its employer mandate one year.

Although today Mr. McDonough notes the differences rather than the parallels between the Dukakis law and the Affordable Care Act, proponents of the national employer mandate should be worried that it may be approaching the end of its political life.

LOAD-DATE: November 13, 2013

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December 11, 2013 Wednesday  
Late Edition - Final